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UNIFIED PROGRAM CONSOLIDATED FORM <br /> F� UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION 13879&B882 PRAD09:186 <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 3 at S300 (Agency Use Only) �1 (f f <br /> F7 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3, <br /> Lawrence Livermore National Laboratory - S300 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> Corral Hollow Road South of Tracy, CA <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> U.S. Government-Department of Energy/NNSA 925 423-8163 <br /> MAILING ADDRESS 409, <br /> P.O. Box 808, L-293; 7000 East Ave, L-293 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Livermore CA 94551-0808 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2, <br /> Lawrence Livermore National Security, LLC (925) 422-6920 <br /> MAILING ADDRESS 428-3. <br /> P.O. Box 808, L-627; 7000 East Ave, L-627 <br /> CITY 4284 1 STATE 428-5. ZIP CODE 428-6. <br /> Livermore CA 94551-0808 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> U.S. Government-De artment of Ener /NNSA (925) 423-8163 <br /> MAILING ADDRESS 416. <br /> P.O. Box 808, L-293; 7000 East Ave, L-293 <br /> CITY 417, 1 STATE 418. 1 ZIP CODE 419. <br /> Livermore CA 94551-0808 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ® 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 ®� Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: [11.FACILITY OWNER ® 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406' <br /> .. . <br /> Sav Mancieri <br /> VII. Ak'PLICANT SIGNATURE <br /> CERTIFICATION: I cortify that the information provid d herein is true,accurate,and i full compliance with legal re uireme"ts. <br /> TU DA E 424 PHONE 425, <br /> ;2�= <br /> tC'r. 4 lT 925 422-692()...` :) <br /> APPLICANT NAM (print) 426, APP CANT T1TLE �� 427 <br /> Sav Mancieri Division Leader, Permits and Regulatory Affairs Divisio,"<' <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />