COMPLIANCE INFO_FILE 11 - Laserfiche WebLink

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r 00 Cgoumccs STATE OF CALIFORNIA Aq r �O 7 STATE WATER RESOURCES CONTROL BOARD dam, UNDERGROUND STORAGE TANK PERMITLI I -FORM Ams COMPLETE THIS FORM FOR EACH FACILITY/SITE • C'l,ppq N• MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME CARE OF ADDRESS INFORMATION NAME OF OPERATOR U.S_ Government - t of Energy Lawrence Livermore National Laboratory, Site 300 7000 East Avenue, L-627 (P.O. Bos 808) C. Susi Jackson ✓ box to indicate 0 INDIVIDUAL ADDRESS 1301 Clay Street NEAREST CROSS STREET COUNTY -AGENCY FEDERAL -AGENCY PARCEL • (OPTIONAL) Corral HolloK Road ZIP CODE U.S. 43 580 PHONE # WITH AREA CODE Oakland CITY NAME 94612-5208 STATE ZIP CODE SITE PHONE # WITH AREA CODE Limmomm CA 94550 (925) 423-6577 ✓ BOX Q CORPORATION Q INDIVIDUAL a PARTNERSHIP LOCAL -AGENCY ® COUNTY -AGENCY ° ® STATE -AGENCY' ® FEDERAL -AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency, complete the following: name of supervisor of division, section or office which operates the UST TYPE OF BUSINESS ❑ y GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) RESERVATION Q 3 FARM ® 4 PROCESSOR ® 5 OTHER7ORTRLISTLANOS 5 CA2$90090002 11. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS U.S_ Government - t of Energy None 7000 East Avenue, L-627 (P.O. Bos 808) MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY Q STATE -AGENCY 1301 Clay Street ® CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE 194550 PHONE # WITH AREA CODE Oakland CA 94612-5208 1(510) 637-1595 NAME OF OWNER Lawrence Livermore National Laboratory CARE OF ADDRESS INFORMATION 7000 East Avenue, L-627,(P.O. Bos 608) MAILING OR STREET ADDRESS ✓ box to indicate ® INDIVIDUAL LOCAL -AGENCY STATE -AGENCY 7000 East Avenue, L-627 (P.O. Bos 808) O CORPORATION ® PARTNERSHIP ® COUNTY -AGENCY ® FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE Livermore CA 194550 (925) 423-6577 TY (TII HO F4–]-4]—-1 ■■■■■ ✓ box to iIndicate 9 SELF-INSURED ® 2 GUARANTEE ® 3 INSURANCE ® 4 SURETY BOND ® 5 LETTER OF CREDIT ® 6 EXEMPTION ® 7 STATE FUND I (� 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM ® 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTEU SIGNATURE) TANK OWNER'S TITLE operations and DATE MONTHIDAYNEAR C_ Susi Jackso Regulatory Affairs Division Lee er I At' AI A^0kInV IIQ!_ AG11 V COUNTY # JURISDICTION # FACILITY # EE � �� CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL OWNER FORM WITH THE LOCAL STORAGE TANK REGULATIONS FORM A (6-95)