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e � 4 <br /> ENVIRONMENITAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT 0 ®18(j <br /> APPLICATION FOR PERMANE-1.4 %1PORARY CLOSURE OR ABANDONMENT <br /> IN PLA('E OF UNDERGROUND HAZAR )OLiS_SI iBSTANCE STORAGE TANK, <br /> THIS PERMIT EXPIRES 9)DAYS FROM THE APPROVAL DATE. <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _REMOVAL TL-'MM)RARY CLOSI!RE CLOSURE IN PLACE <br /> EPA Site = t'r.a�a ('utttact& Tcict+hune x <br /> F (•A2SYww;(wxl2 <br /> (' Susi la.i.ra(5;u;.t2;_•c,- <br /> A Facility N.nne inion# <br /> C Lawrence Livemwre Natimid LaNin tory(LLN.1-).Site 14) (510)423--1881 <br /> I yds a� <br /> L Corral Hollow Road.(southwest of Trcv) <br /> I Cross Street <br /> T ,k2groxiniatelv 3 mites wem of Highway 590 <br /> Y Owner/OperatorPhone# <br /> f California (510)423-6577 <br /> ITS. De artrnent o Energy.University o <br /> Contractor Name Phone# <br /> O Contractor Addrebb CA Ltc# C <br /> N 2AS Gomm c. S90als. I AHMAI <br /> T Insurer Work.Comp.# <br /> R <br /> -T S, IaTLEIJTS PW -� O 4-00 <br /> A Fire District Pernut# <br /> C LLNL. Site 300 Fire artnhent Phone# <br /> T Laboratory Name (510)426-26(X) <br /> O Clayton Environmental Consultants Phone# <br /> Sampling F' (510)423-6577 �1 <br /> LLNL.Envie ntal ection e"t <br /> Tank ID # Tank Size Chemicals Stored Carrentiv/Previoosl Date UST Installe <br /> 39- 10.000 eallons unleatk:d�_axtiine 1975 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Approved Approved with Condition(s) <br /> Disapproved <br /> L (See Attachment with onditions) <br /> A <br /> N Plan Reviewers Name <br /> ADD! It'P..'vT h+t;,`-i'PFRFOR.'�1 ALL WORK u^�ACCORU�1:'�CE w'rtH SAN 1()AQt�1 CO ORDLNAI'3CES.STATE LAW..AND <br /> SED AG3�TS <br /> R''LES -ND REGULATIONS OFN SAJUA(XL'`N COL"-.Y?UBLIC'F EAL rri SERV ICES. OWNER OR LICEN <br /> SIGNATURE CERTIFIES THE FOLLOWING. -I CERTIFY THAT IN THE PERFORMANCE OF HE WORK FOR WHICH TrUS PERb1IT <br /> IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> LAW'S OF C !,:--j2.,:3=x.' CONTMACTOP.'S' NG C'R SU IiCt)i4[RA ^-'uNG SIGNATURE CERTIF-S THE FOL'_OWNG: -1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS <br /> SUBJECT TO WORKER'S COMPENSATION LAW OF CALIF )RMA- <br /> SI( `AT7 DATE <br /> APPLICA-N-r RT <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />