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ENVIRONMENTAL HEALTH DIVISION OW 2 t V <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 /> X 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 Laboratory ,Site 3001(510)423-4881 <br /> I Mailing Address:7000 East Avenue,P.O.Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road south of Tracy,CA <br /> I Cross 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 /> C Contractor Name 9 Phone# <br /> yon <br /> O Contractor Address CA Lic# Class <br /> N 9 a Gohr, %r%VLA 125-r '-V3w CA 5qd 5 -144 <br /> T InsurerWork Comp.# <br /> R ZI,F A Qoe, -9Q034-00 <br /> A Fire District Permit# <br /> C LLNL Site 300 Fire Department <br /> T Laboratory Name Phone# <br /> O Clayton Environmental Consultants (510)426-2600 <br /> R Sampling Firm Phone# <br /> LLNL,Environmental Protection Department1(510)423-6577 <br /> Tank ID # Tank Size Chemicals Stored Currently/Previousli Date UST Installe <br /> 39- q q5--07 280 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 (See Attachment with Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I 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 CALIFORNIA' CONTRACTORS IMUNG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS <br /> SUBJECTTO WORKER'S COMPEN A NLACALIFORNIA." <br /> APPLICANTS SIGNATURE: TITLE CA i. u DATE �� 3 <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />