Laserfiche WebLink
4INVIRONMENTAL HEALTH DIVISIO10 <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 I Phone# <br /> C Lawrence Livermore National Labm�(L�LNL), 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 TraEy,CA 94550 <br /> 1 Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Highwax 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 NA (LLNL,with contractor to 12erform labor only) <br /> 0 Contractor Address CA Lic# Class <br /> N I I <br /> T Insurer Work.Comp.# <br /> R Self-Insured <br /> A Fire District Permit# <br /> C LLNL,Site 300 Fire Del2artment <br /> T Laboratory Name Phone# <br /> * California Laboratory Services (916) 638-7301 <br /> * Sampling Firm Phone# <br /> LLNL,Environmental Protection DeRart ent (510) 423-4012 <br /> Tank ID# Tank Size Chemicals Stored Currently/Previously Date UST Installed <br /> 39- /4Lt5-31(829-D1U1) 27 gallons Diesel fuel 1983 <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 Attachme with Conditions) <br /> A <br /> N ,Plan Reviewers Nam ee�/7m <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORUANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNSF <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, I 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 /> APPLICANT'S <br /> SIGNATURE: TITLE DATE <br /> EH 23 046(REV 7/10/92) <br /> CLOSURE PLAN: <br />