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EYN'IR0 NNT_NrrAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT 04C LQ <br /> APPLICATION FOR PEp_%4 AN �'VTf EMPORARY CLOSURE OR ABANDONMENT <br /> IN PLACE OF LPNI)ERGROUNI)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 /> _[_REMOVAL TEMPORARY CLOSURE' CLOSURE IN PLACE <br /> EPA Stte 4 PrTect Contact&Telephone# <br /> F CA_89(),lytW2 r S-st Jack,�r.<5101 4:1-6577 <br /> A Facility Name Phone# <br /> C F_awre�re I_i�e reNauunaJ Lab)Mt(,ry iLLNT).Site 300 1 (510)423-4881 <br /> i .,.. ::-,c <br /> L Corral Hollow Road.(southwest of Tracv) <br /> I Cross Street <br /> T A22roxunat-!Iv 3 rules wes_of Highway 58n <br /> Y OwneriOperator Phone# <br /> U.S.De2artment of Enerov. University of California (510)423-6577 <br /> Contractor Name Phone# <br /> 0 Contram Address CA Lic# Class <br /> N 9a5 ComrAtp-t LSr SAN-rast.CA SSI a c�95 Kl-NAZmJ4T <br /> T Insurer Wak.Comp. # <br /> R J.F. Kl nZN TS <br /> A Fire Distract Permit# <br /> C LLNL.Site 300 Fre Department <br /> T Labonatory Name Phone# <br /> O Clayton Environmental Consultants (510)426.2600 <br /> R S F # <br /> LLNL Environmental onDe ent (510)423-6577 <br /> Tank 11) Al Tank Size Chemicals Stored Currentl viousl Date UST Instaiie <br /> • t°1 3 10.000 gallons unleaded easohm/leaded easoline 1968 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Approved Approved with Condition(s) Disapproved <br /> L (See Attachment with Conditions)- <br /> A 2 . <br /> N Plan Reviewers Nana ate .✓- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQM 96UNTY ORDINANCES.STATE IAWS.AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.OWNER OR LIC'E'NSED AGENTS <br /> SIGNATURE CERTIFIES THE F)LLOWT4Cr -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br /> IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> LAWS OF CALToRNIA." COM'RACTORS HMM OR SUBCONTRACTING SIGNATURE CERTMB THE FOLLOWING: "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT LS ISSUED.I SHALL.EMPLOY PERSONS <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE: TiTL.E DATE 7 a <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />