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UNIFIED PROGRAM CONSOLIDATED FORM-TANKS � (P <br /> UNDERGROUND STORAGE TANKS• FACILITY �ti `tjl <br /> 679,G3U1 R'Gr3G05115 <br /> One page per site Pae 1 of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE Of INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)- ❑6.TANK REMOVED <br /> [16, 1 EMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(SameasFACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> t. <br /> Lawrence Livermore National Laboratory-Site 300 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402 <br /> Interstate 580 ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ❑1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403 [:12,INDIVIDUAL [16.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ®6.OTHER ❑3.PARTNERSHIP ®7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation or 405. •If owner of UST is a public agency:name of supervisor of division,section or office which 406. <br /> REMAINING AT SITE trust lands? operates thp.11ST (This is the contact person for the tank records.) <br /> 3 at Site 300 ❑Yes ®No C.Susi Jackson <br /> II, PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> U.S. Government-Department of Ener 925 422-2572 <br /> MAILING OR STREET ADDRESS 400. <br /> P.O. Box 808,L-633;7000 East Ave,L-633 <br /> CITY 410.FSTATE 411, ZIP CODE 412, <br /> Livermore I CA 94551-0808 <br /> PROPERTY OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME ala, PHONE 415, <br /> Lawrence Livermore National Laboratory 925 423-6577 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O. Box 808,L-633;7000 East Ave,L-633 <br /> CITY 417 STATE qts ZIP CODE 419. <br /> Livermore CA 94551-0808 <br /> TANK OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44 I& Exempt Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> - - -- --------- <br /> INDICATE METHOD(s) El 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99 OTHFR- <br /> ❑3.INSURANCE 1816.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box t o(2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the inform tion provided herein is true and accurate to the best of my knowledge. <br /> SIG OF PPLICANT DATE 424. PHONE 425, <br /> cl l•D (925)423-6577 <br /> OF APPLICANT(prin 426. TITLE OF APPLICANT 427, <br /> C.SUSI Jackson Division Leader,Operations and Regulatory Affairs Division, <br /> Environmental Protection Department <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UNCF 11wfwrc-a(1/99)-1/2 hitp://www.unidocs.org Rev.02/16/00 <br />