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- o <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT07Ek PORARY 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 8t.Telephone# <br /> F CA28 C.Susi Jackson 510 423-6577 <br /> A Facility Name Phone# <br /> C Lawrence Livermore National 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,much of TraSI <br /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road Tesla Road and Hi hwa 580 <br /> Y Owner/Operator.U.S.Government-Department of Energy, Phone# <br /> Universi of Califomia 510 423-6577 <br /> Contractor Name Phone# <br /> C CQ la `IDS,4S3- 11w <br /> O Contractor Address CA Lic# C12ss <br /> N qjA5 CO tnn u u_ST N�sc C1� Sq O3tgS- W-NAZ <br /> T Insurer Work.Comp. # <br /> R ,4 NTS — O '00 <br /> A Fire District Permit# <br /> C LLNL.Site 300 Fire Deparment <br /> T Laboratory Name Phone# <br /> O Cla n Environmental Consultants 510 426-2600 <br /> C R Sampling Firm Phone# <br /> LLNL.Environmental Protxtion enc L5191 423-6577 <br /> Tank ID 4 Tank Size Chemicals Stored Currentiv/Previousli Date UST Installs <br /> 39- �i S— 300 itallons 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 (S ttachment with Conditions) <br /> A <br /> N Plan Reviewers Name Date v iL <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SIN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUN'T'Y PUBLIC VALTH SERVICES.OWNER OR LICENSED AGENT'S <br /> SIG'4ATURE CERTU..S i iE FOLLOW WG: "I CERTIFY THAT LN ...PERFORMANCE OF THE WORK FOR VtMCH THIS PMUT <br /> IS ISSUED.I SHALL.NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKERS COMPENSATION <br /> LAWS OF CALIFORNIA." CONTRACTORS HVING OR SUBCONIRACIING SIGNATURE CERTIITFS THE FOLLOWING: 'I <br /> CERTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH TIM PERMIT IS ISSUED.I SHALL EMPLOY PERSONS <br /> SUBJECTTO WORKERSCOMP OFCAIIPORNIA' <br /> F <br /> APPLICANT'S SIGNATURE: TfILEC4IJS'f. A tv 6 DATE <br /> EH 23 046(REV 7/10/92) <br /> t <br /> 3 <br />