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ENvVtONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> ICATION FOR PERMANENTfrEM?ORARY CLOSURE OR ABANDONMENT <br /> IN <br /> BANDO - <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK• <br /> THIS PERMIT ExputES 90 DAYS FROM THE APPROVAL DATE. <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> _REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA Site N Project Contact dt Teiephone Y <br /> F CA29900900M C.Susi Jackson 510 423.6577 <br /> A Facility Name Phone# <br /> C Lawrence L' National L&Z= Site 300 ]_(512)423-Ml <br /> I Mailing Addre=7000 East Avenue,P.O.Box SM.Livermore.CA 94550 <br /> L Site Address:Corral Hollow R south of T <br /> I Cross Sava <br /> T krcated 15 mr7es test of Livermore on Corral Hollow Road Tesla Road and Hi h S80 <br /> Y ownatopetalor Phone 4 <br /> U.S.Gov Universi ofCalifornia S 1 423-6577 <br /> Cotma=Nam phone# <br /> C V11=t%* <br /> HCam=Aft= <br /> ClCA rngru t.SS CA L.icS CIMA <br /> T InsurerWork Comp.t <br /> R <br /> A Fire Distria Permit 4 <br /> C Site 300 Fire a nt <br /> T LabwAory Nance phone N <br /> O Cla Eavitonmental Consultants 5 M 426.2600 <br /> R Sampling Fam phone• <br /> Esr t LSIM 4 <br /> Tank p Took Size Chemicals Stored Carreotl tPrevioust Date UST tastatle <br /> 39- 8DW ggl6ns dieri fuel 17 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Approved _ Approved with Cond'etioa(s) Disapproved <br /> L (See ttac.meat with Conditions) <br /> A L—,//"'V <br /> N Plan Reviewers Na Dat <br /> APPL)C.ANT MUSE AIL WORK IN ACCORDANCE WITH OOUN9Y ORDWANCES.STATE LAW'S.AND <br /> RULES AND OF SAN HEALTH SFR OR ®AGOM <br /> SXWATURF TI4E FC1 Z THAT IN THE NCE OF THIS PERMIT <br /> IS ISSUED.I SHALL NOT DAnM ANY PEtSON IN SUCH A MANNER AS TOB SUBECT'1O S CORENSATION <br /> LAWS OF C.ALIPORNLA CWMACTORS H RM OR SLMCONMACTM WC NATURE CEMW THE G: 7 <br /> THAT 1NTHE = F THE WDRK FOR WHICH THIS 1S 15SI1EZI.I SHALL D41+IAY S <br /> 'IU S • <br /> APPLICANTS SIGNATURE: TM-E DATE +O b <br /> EH 23 046(REV 7/1W92) <br /> 3 <br />