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07/16/04 08;12 FAX 925 422_4 EPD / WGMG U002 <br /> UNIFIED PROGRAM CONSOLIDATED FORM TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page I of I <br /> TYPE Of ACTION ❑I.NEW PERMIT D 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION 0 7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [3 4.AMENDED PERMIT Specify change local use only 8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> Ali, "-IlejI <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Hissinow As) 3 <br /> FACILITY g n <br /> Lawrence Livermore National Lab(LLNL)-Site 300 <br /> TD# <br /> NEAREST CROSS STREET 4m. FACILITY OWNER TYPE U 4,LOCAL AGENCY/DISTRICT* 402. <br /> Interstate 580 [:] I.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS 0 1.GAS STATION [13.FARM [15.COMMERCIAL 4 El 2.INDIVIDUAL 0 6.STATE AGENCY* <br /> TYPE 0 2.DISTRIBUTOR E3 4.PROCESSOR 0 6.OTHER [13.PARTNERSHIP 0 7.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS 404. is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (Ibis is the contact person for the tank records.) <br /> 3 at Site 300 ❑Yes No C. Susi Jackson <br /> "Him <br /> `Mll <br /> 3i <br /> N-1-1111"'I <br /> PROPERTY OWNER NAME 07. IPHONE 40. <br /> U.S.Government-Department of Energy-Livermore Site Office 925-423-8163 <br /> MAILING OR STREET ADDRESS 409, <br /> P.O.Box 808,L-574 <br /> CITY410. STATE 411. 1 ZIP CODE 412. <br /> Livermore CA 94551-0808 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION [12.INDIVIDUAL [:j 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY 413. <br /> 1:13.PARTNMHM 1:15.COUNTY AGENCY 7.FEDERAL AGENCY <br /> "IE"'lig. ;j <br /> All..mll"'1!41! 11 <br /> TANK OWNER NAME 414. PHONE 415. <br /> LLNL-Site 300 925-473-6577 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 808,L-627 Attn: William G.Ho es <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Livermore I CA 94551-0808 <br /> TANK OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY 420. <br /> 0 3.PARTNERSHIP Q 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> !ill IJ4 <br /> 1!g <br /> *I*N" <br /> 11.1- _­­111�N_ <br /> '11110ril!1.;;.4.. <br /> -40 <br /> M:Ufl... 1014*11- !wu`�111111 ffil"m 141, <br /> TY(TK)HQ 44- NA Call(916)322-9669 if questions arise 421. <br /> 'Id",ll <br /> n! <br /> ........... <br /> ­­11,­1111,11 wi; <br /> I <br /> ;®r <br /> INDICATE METHOD(s) [3 1.SELF-INSURED 0 4.SURETY BOND 0 7.STATE FUND [3 10.LOCAL GOVT MECHANISM 422. <br /> [3 2.GUARANTEE [3 5.LETTER OF CRIKDIT []8.STATE FUND&CFO LETTER [3 99.OTHER: <br /> 0 3,INSURANCE 196.EXEMPTION [3 9.STATE FUND&CD <br /> IN i1iiiII <br /> I Jul I <br /> id -rj, Ir. uttp_, <br /> I! 11 ,1N 1 <br /> zili <br /> Check one box to indicate which address should be used for legal notifications will mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. 0 1.FACILITY [12. PROPERTY OWNER 3.TANK OWNER 423. <br /> 1-47 <br /> -,1111,.I1-'` , - <br /> fflf iloil!�Il <br /> i1jrEi .!e;;ia.Irjl.il 1!!l"j'I4 1":Iijlj�� 11'11111�1 <br /> .. .... JrI VIIl.P' <br /> Ei <br /> Min 0;'R 1;'!!"1 i I", !I*,IF I.; <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN>W<O "PLICANT DATE 424, 1 PHONE 423. <br /> -?-2S--q23- is? 7 <br /> NAME OF APPLICANT(print) 426- TITLE OF APPLICANT 427. <br /> C. Susi Jackson Division Leader,Environmental Protection Department <br /> 1 STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> 871-DIU2,875-DIU2 <br /> UPCF(1/99 revised) Formerly SWRCB For m A <br />