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ONMENTAL HEALTH DIVISI <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 Phone# <br /> C Lawrence Livermore National Laboratory (LLNL), Site 30 (510) 423-6577 <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 /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and Hi hwa 580) <br /> Y Owner/Operator:U.S.Government-Department of Energy. Phone# <br /> Universitz of California (510) 423-6577 <br /> Contractor Name N/A Phone# <br /> C <br /> O Contractor Address CA Lic# Class <br /> N <br /> T Insurer Work.Comp.# <br /> R <br /> A Fire District Permit # <br /> C LLNL, Site 300 Fire Dej2artment <br /> T Laboratory Name Phone# <br /> O California LaboratoryServices (916) 638-7301 <br /> R Sampling Firm Phone# <br /> LLNL, Environmental Protection De artment (510) 4234012 <br /> Tank ID# Tank Size Chemicals Stored Currentlx/Previously Date UST Installed <br /> 39- 1045 ; tt 280 gallons diesel fuel Unknown <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 Nameate <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE WITH AN 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, 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 /> r <br /> APPLICANT'S <br /> SIGNATURE: __ / TITLE__ <br /> — — - -�� DATE--- _� — — ------ <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />