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ENVIRONMENTAL HEALTH DIVISION <br /> 0 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <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 /> --L—REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA Site# Project Contact&Telephone# <br /> F CA2890090002 C.Susi Jackson 510 423-6577 <br /> A Facility Name Phone# <br /> C Lawrence Livermore National La ),Site 300 510 423-4881 <br /> I Mailing Addre=7000 East Avenue,P.O.Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road,south of Tracy,CA <br /> I Goss Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Highway 580) <br /> Y Owner/Operator Phone# <br /> U.S.Government,University of California (510)423-6577 <br /> Contractor Name n Phone# <br /> C 901 -q53- )ti-I <br /> O Contractor Address CA Lic# Class <br /> N a5 C4tn w.e 4�s CA Sq0 S -�1A <br /> T Insurer Work Comp.# <br /> R I,F- AtveJ--i,S WC - 3 L1-OO <br /> A Fire District Permit# <br /> C LLNL.Site 300 Fire Deparunent <br /> T Laboratory Name Phone# <br /> O Clayton Environmental Consultants (510)426-2600 <br /> R Sampling Firm Phone# <br /> LLNL.Environmental Protection Department 510 423-6577 <br /> Tank ID # Tank Size Chemicals Stored Currently/Previous) Date UST Installe <br /> 39 S-O 280 gallons diesel fuel 1967 <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 (Se Attachment wi Conditions) <br /> A ,<J / <br /> / , - G <br /> N Plan Reviewers Name �' i // V Date / V <br /> APPLICANT MUST PERFORM All.WORK IN ACCORDANCE WITH SAN PAQUIN COUNTY ORDINANCES.STATE LAWS,AND <br /> RULES AND REGULATIONS OF SAN FOAQUIN COUNTY PUBLIC HEALTH SERVICF_S. OWNER OR LLCINS®AGENTS <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN CE OF THE WORK FOR WHICH THIS PERMTr <br /> IS ISSUED.I SHALL NOT EMPLOY'ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECTTO WORKERS COMPENSATION <br /> LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I <br /> CER7 Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS <br /> SUBJECTTD WORKER'S COMPEN =NLA CALIFORNIA." <br /> APPLICANTS SIGNATURE: TITLE CA i. v DATE a-) 3 <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />