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4knRONMENTAL HEALTH DIVISION 0 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENTrrEMPORARY CLOSURE OR AB 9t <br /> C@n4 fi °� 4b A�°' ' Itw i�S�3 <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES Gfi'T r, r <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVALliM . ' i k <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERK Tq EL9T, :,. <br /> 10 3''11 <br /> XREMOVAL 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 Labora 2AM2 Site 300 1 510 423-4881 <br /> I Mailing Address:7000 East Avenue,P.O.Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road south of jpcy,CA 94550 <br /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road(between Tesla Road and HiShwa 580 <br /> Y Owner/Operator.U.S.Govemment-Department of Energy, Phone# <br /> Universi!x of California L510 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 Re ublic Indemni <br /> A Fire District Permit# <br /> C LLNL Site 300 Fire De artment <br /> T Laboratory Name Phone# <br /> O Clayton Environmental Consultants 510 426-2600 <br /> Sampling Firm Phone <br /> LLNL,Environmental Protection De ent 510 4234012 <br /> Tank ID # Tank Size Chemicals Stored Currentll/Previousil Date UST Installe <br /> 39- 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 I Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH 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: 'Z CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br /> IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> LAWS OF CALIFORNIA-" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'Z <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 /> APPLICANT'S SIGNATURE: l TITLE Q°f oQp-. DATE <br /> !o y <br /> Le <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />