COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

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UljJIED PROGRAM CONSOLIDATED FfM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ of _ TYPE OF ACTION j 1.NEW SITE PERMIT rX 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE (Check one item only) r 4.AMENDED PERMIT local use only) r S.TANK REMOVED 400 r 6.TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# Lawrence Livermore National Laboratory Site 300 NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYIOISTRICT- On Corral Hollow Road near I-580 r 1. CORPORATION r 5. COUNTYAGENCY' BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL ENCY- r 2.DISTRIBUTOR r 4.PROCESSOR IX6.OTHER r 3. PARTNERSHIP r 6. FEDESTATRAL AL AGENCY- 7. FEDERAL AGENCY' 402 403 TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of REMAINING AT SITE trustlands? division,section or office which operates the UST. (This is the contact person for the tank records.) 4o4 5 rYes No 405 406 William G. Hoppes II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 U.S. Department of Energy 1(510) 637-1595 MAILING OR STREET ADDRESS 409 1301 Clay Street CITY 410 STATE 411 ZIP CODE 412 Oakland CA 94612 PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY 7. FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Lawrence Livermore National Laboratory 1(925) 422-0158 MAILING OR STREET ADDRESS 416 LLNL, P.O. Box 808 L-627 Attn: William G Hoppes CITY 417 STATE 418 ZIP CODE 419 Livermore ICA 94551-0808 TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY 7. FEDERAL AGENCY 1v RQAE?D OE 1=01'A' IZATION 11431 STORAGE EME ACC01 INT N'IMBEIR TY(TK)HQ 4 4 Call(916)322-9669 if questions arise Not applicable. 421 INDICATE METHOD(S) 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r 99. OTHER: r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 'C�her�kT�n;box toindicate which address should be used for legal nofrfications and mailing. r 1. FACILITY r 2. PROPERTYOWNER j'3. TANKOWNER 423cations and matlin swill be sent to the tank owner unless box 1 or 2 is checked. Cart rfica l n: I certify that the inform ion provided herein is true and accurate to the best of my knowledge. SI TURE CANT DATE_ 424 PHONE 425 !r L. 1 c 925 423-3176 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 C. Susi Jackson Division Leader. Affairs Division Environmental Prnteet STATE UST FACILITY NUMBER(For local use only) 428 1996 UPGRADE CERTIFICATE NUMBER(For local use only) 429