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OtiSMN-rAL HEALTH DIVISION j�5T879-(�114� <br /> E,w tR . <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMrr 0MC.803 <br /> APPLICATION FOR PE3L%fA..NLNT[ENPO Y 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 PERMU TYPE BELOW: <br /> __X_REMOVAL TEMPO Y CLOSURE' CLOSURE IN PLACE <br /> EPA Site i Protect Contact&Telephone 0 <br /> F CA28009(M2 C.5.�r Jack;.r.e51Ct:_?-R4-- <br /> A Facility Name Phone 6 <br /> C '-awrt-c-t►.i%c"ore Nm kcal Lat•-raton•ILL! ).Site 300 (510)4234881 <br /> i .az—tz.; <br /> L Corral Hollow Road.(southwest of Tracv) i <br /> I Cross Street <br /> T A roam-weiv 3 rW-es wes-of Hiehwav 58n <br /> Y Ownetioperaw Pboneis <br /> U.S.Dwnment of Enemy.University of California (5 t0)423-6577 <br /> C Con *9000-y5 -t�� <br /> 0 Contractor Address CA Lic is Class <br /> N 9.15Clomrn 1.5rSAwSost-CA Sgoag5 A"NAZ.fnT <br /> T hiswer Work.Comp.S <br /> R Z.F. IAn.enrrs <br /> A Fire Drstnct Permit tf <br /> C LLNL.Site 300 Fire 2Marunent <br /> T Pbone 0 <br /> O am Environmental Consultants (510)4262600 <br /> It4 <br /> LLNL Ea tat Deparanent 1'(510)423-6577 <br /> T N Tank Size Chemicals Stored Currently/Previous!, Date UST lwtalled <br /> 39- 10.000 gallons unleaded easoline!leaftd toolim 1 <br /> 968 <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 Condittoas) y� <br /> N Plan Reviewers NameZate <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUINPUNTY ORDINANCES.STATE LAWS.AND <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.OWNER OR LICENSED AGE%TS <br /> sm NATURE Comm THE FOLLOW DIG: -1 CERTIFY THAT IN THE PsFORmANCE OF THE WORK FOR WHICH THIS PMTr <br /> IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S SATION <br /> LAWS OF CMZORNW CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTWIES THE FOL LOWINQ "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 /> APPLICANTS SIGNATLrRE: TITLE DATE i a <br /> EH 23 046(REV 7/10/92) <br /> 3 <br />