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Ak <br /> WIVIRONNIENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENTaEMPORARY CLOSURE OR AB <br /> TAI <br /> 7T Iq <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STOR]AGit,*K, yy A L <br /> THIS PERMIT EXPIRES go DAYS FROM THE APPROVAL DATE.-- <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE ,PERMIT TYP," -9_ F �'; 9: 10 <br /> ;4 <br /> _REMOVAL._TEMPORARY CLOSURECLOSUREIN PLACE <br /> EPA Site# Project Contact&Telephone# <br /> F CA2890090002 C.Susi Jackson (51 )423-6577 <br /> A Facility Name I Phone# <br /> C Lawrence Livermore National Labors Site 300 1 C5 IQ 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 /> 1 Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Highway 582) <br /> Y Owner/Operator.U.S.Government-Department of Energy, Phone# <br /> University of California (510)423-6577 <br /> Contractor Name N/A Phone# <br /> C <br /> 0 Contractor Address CA Lic# Class <br /> N I I <br /> T Insurer Work. Comp.# <br /> R Re2ublic Indemni!X <br /> A Fire District Permit# <br /> C LLNL,Site 300 Fire Re <br /> .Rartment <br /> T Laboratory Name Phone# <br /> 0 Clayton Environmental Consultants,Inc. (510)426-2600 <br /> R Sampling Firm Phone# <br /> LLNL,Environmental Protection De artment (510)423-4012 <br /> Tank ID # Tank Size Chemicals Stored Current) /Previous) Date UST Installed <br /> 39- 300 gallons diesel fuel 1972 <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 Attachment with Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WrM SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr <br /> IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKERS COMPENSATION <br /> LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> J r 1— <br /> --i-siv, DATE <br /> APPLICANTS SIGNATURE !A� L92 TITLE b� <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />