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t ` <br /> Milk <br /> .. - SENT BY:Xerox Telecopier 7021 ; 16—94 ; 9:01AM ; 9163811622;# 4 <br /> EN'V RONMBNTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION ICOR 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 /> P CA2890090002 C.Susi rackson 510 423.6577 <br /> A Facility Name I Phone+� <br /> C Lawrence Livermore National Laborato LNL),Site 300510 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 94550 <br /> I Cross Street <br /> T Iocated 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Highway 580 <br /> Y Owner/Operator:U.S.Government-Department of Energy, Phone# <br /> University of California 510 423-6577 <br /> Contractor Name Phone# <br /> C ARONSON ENGINEERING INCORPORATED 916-381 -1600 <br /> O Contractor Address CA Lic# Class <br /> N 6809 McComber Street 592010 _ <br /> Haz <br /> T Insurer Work. Comp.# <br /> R Golden Eagle Insurance _ <br /> A Fire District Permit# <br /> C LLNL,Site 300 Fire De artrnent <br /> T Laboratory Name Phone# <br /> 0 California Laboratory Services 916 638-7301 <br /> R Sampling Firm Phone# <br /> LLNL Environmental Protection Department 510 423-4012 <br /> Tank ID # Tank Size Chemicals Stored Currentl /PE!Xj2 sI Date UST Installs <br /> 39- <br /> 2,000 gallons diesel fuel 1982 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> PApproved Approved with Condition _—Disapproved <br /> Aisapproved <br /> L (See Attwent with Conditions) <br /> A /7 <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J AQUIN COUNIY ORDINANC CPS STATE LAWS,AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGINTS <br /> SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br /> IS ISSUED,I SHALL,NOT Fv.�OWY ANY PERSON IN SUCH A MAND-M AS TO BECOME SUBJECT TO WORIMR S C'OMpLNSAIION <br /> LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I <br /> CER71FY THAT IN THE PERFORMANCE OF THE WORJ FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS <br /> SUBJECT TO WORKER'S COMPENSATION LAWF RNIA" <br /> APPLICANT'S SIGNATURE: TITLE Vi c ie Pres ATB 1 – <br /> EH 23 046(REV 7/10192) <br /> a <br />