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WIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMI <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONTMDv 1 <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 Faciiity Name Phone# <br /> C Lawrence Livermore National Laboratory (LLNL), Site 34(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 Tracv,CA 94550 <br /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road (between Tesla Road and Highwav 580) <br /> Y Owner/Operator. U.S.Government-Department of Energy Phone# <br /> Universitv of California (510) 423-6577 <br /> Contractor Name Phone# <br /> C NA (LLNL. with contractor to perform labor oniv) <br /> O Contractor Address CA Lic ;; Class <br /> insurer Work. Comp. <br /> R Self-InsuFed <br /> A Fire Distnct Permit # <br /> C LL.Iti1, Site 300 Fire Department <br /> T Laboratory Name Phone# <br /> O 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 Currentiv/Previousiv Date UST Installed <br /> 39-fJMS-f D1 U1) 1,000 gallons Diesel fuel 1960 <br /> T 39- <br /> A 39- j <br /> N 39- <br /> 39- <br /> 3a <br /> 39- <br /> P Approved Approved with Condition(s) Disapproved <br /> L (See Attachment with Conditions) <br /> A n ' <br /> N Plan Reviewers Name L(�✓'� Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNS <br /> OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANTS <br /> SIGNATURE:_ _ ------___TITLE [_ro <br /> -- DATE <br /> EH 23 046(REV 7/10/92) <br /> a.oscE FLAN: 834-DIU: <br />