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0000n <br /> ENVIRONMENTAL HEALTH DIVISION <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 CLOSURECLOSUREIN PLACE <br /> EPA Site# Project Contact&Telephone# <br /> F CA2890090002 C.Susi Jackson (5102 423-6577 <br /> A Facility Name Phone# <br /> C Lawrence Livermore National jt2�aLL4Q,Site 300 1(510)423-4881 <br /> 1 Mailing Address- 7000 East Avenue,P.O.Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road,south of Tracy <br /> I Cross Sam <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and HiShMax 580 <br /> * Owner/Operator.U.S.Government-Department of Energy, Phone# <br /> Universi!X of California (510)423-6577 <br /> Contractor Name Phone# <br /> C T"LM rlkoaT Ut= LJQS-45�,- <br /> * Contra=Address CA Lic# <br /> N Sq oaqT <br /> T Insurer Work.Comp. # <br /> R ;1,4V. NTS - 03q-00 <br /> A Fire District Permit# <br /> C LLNL,Site 300 Fire Department <br /> T Laboratory Name Phone# <br /> 0 Clan2n Environmental Consultants (510)426-2600 <br /> R Sampling Firm Phone# <br /> LLNL,Environmental Protection ent 1(510)423-6577 <br /> Tank ID # Tank Size Chemicals Stored Currently/Previoust Date UST Installed <br /> 39-1014 300 gallons diesel fuel 1978 <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 ,7(See Attachment with Conditions) <br /> A <br /> N -Plan Reviewers Na Date Date /— ,le—, <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH S JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC SERVICES.OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERT=T,HE FOLLOWING: I CERTIFY THAT pERFOp_k1ANCE OF THE WORK FOR%VMCH THIS PERMIT <br /> I S* <br /> IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT'TO WORKERS COMPENSATION <br /> LAWS OF CALT<)RNLA-- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I <br /> CERTIFY THAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS <br /> SUBJECT TO WORKER'S C(GWW7 FCAL11:1ORNIA." <br /> 'ZJJJtA <br /> f�O <br /> Tt--XT A TlTLE QOWSf, 0 6, DATE <br /> APPLICANTS SIGNATURE:TDIC- <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />