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.4 NMENTAL HEALTH DIVISION <br /> APPLICATION PW UNDERGROUND TANK CLOSURE IT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK. <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. <br /> DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA Site # Project Contact&Telephone# <br /> F CA2890090002 C.Susi Jackson (510)14123-6577 <br /> A Facility Name Phone# <br /> C Lawrence Livermore National Laborato (LLNL), Site 3 (510) 423-6577 <br /> I Mailing Address:7000 East Avenue,P.O. Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road,south of TraSZ,CA 94550 <br /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Hi hwa 580) <br /> Y Owner/Operator:U.S.Government-Department of Energy Phone# <br /> Universi of California (510) 423-6577 <br /> Contractor Name N/A Phone# <br /> C <br /> O Contractor Address CA Lic# Class <br /> N <br /> T Insurer Work.Comp.# <br /> R <br /> A Fire District Permit # <br /> C LLNL,Site 300 Fire Dej2artment <br /> T Laboratory Name Phone# <br /> O California Laboratory Services (916) 638-7301 <br /> R [Sampling Firm Phone# <br /> LLNL,Environmental Protection Depart ent (510) 4234012 <br /> Tank ID# Tank Size Chemicals Stored Current l lPreviousl Date UST Installed <br /> 39- 3b-DWI 280 gallons diesel fuel Unknown <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- _Disapproved <br /> --.4 Approved <br /> 9- <br /> 39- <br /> 39- <br /> Approved Approved with Condition(s) Disapproved <br /> L (See Attachment with Conditions) <br /> N I Plan Reviewers Named <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNS <br /> OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA:' <br /> APPLICANT'S,,, r( ,/�� <br /> SIGNATURE: c.--- 11— �_ TITLE_ _�_o__LsG DATE___S�` _�0 _ �2______ <br /> EH 23 046(REV 7/10/92) <br /> 3 <br /> 83D <br />