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EI�(VQZ TAL t�ALTH(XVISION _.. # , . <br /> APPLICATIt)N FOR UNDERGRUt;ND TANK CLOSURE PERMIT X () <br /> APPLICATION FOR /I'E.MPORAR':t CL®SURE OR AB NMENT <br /> M t.E OF LINDERGROLtND HAZARDOLTS,S1.BSTA- CE STORAGE TANK. <br /> THIS pERMrr EXPIRES 90 DAYS FROM THE APPROVAL DATE. : <br /> DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> —x— MOVAL WARY('I.OSI IRE f'LUStJRE IN PLACE <br /> EPA Site s t',,td.t Coista`'t&TOcrIl tic 8- <br /> F CA-)Sy1rd1Y1, t- SU%? o111'.422..57 <br /> A F:xdtty Mantle Plumm x <br /> C LawrWlce Lh-cmuwr Na itma)Lahrrlttxv(LL%1-1.Site?+K) (S oi423-UEI <br /> I <br /> L Ctxral Hollim Roa 1.Nuhweiu o(Tracy) <br /> I CRM Sam <br /> T AMumteiv?mike we%t of Highway 5R(1 <br /> Y ownexxverair <br /> U.S. De nt of Energy ,Univer0ty of Califixni.-t COO,rxu)r Nam <br /> (310)423-6377 <br /> C <br /> O Coxunc�w Atklrcai CA l.ic N Claus <br /> N ` S402 S 14.4= <br /> T wu&Como.N <br /> R ?.E. TS PW --= 4-00 <br /> A Fire District Perattt <br /> C LLNL.Site VI)Fitt Derament <br /> T Lahxam Nalne Pbocc S <br /> 0 Clavttxl Env' ml Comulmiltc (310)426-26on <br /> It Sampling F' PboncN <br /> LLNL Envin c'nt (51o)423-6577 `1 <br /> Ta IDN Tank Size Chemicals St d Currently/Pro lv asl Date UST Instal <br /> 3y. <br /> 10.000 gallon` un .d e:c 0ine 1973 �" <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39. <br /> 39- <br /> 3 Approved Approved with Comlditioa(s) Disapproved <br /> L (See Attachment with Cuoditium) t� <br /> A �7 <br /> N Plan Reviewers Name to <br /> AP !L:A.%-T ST PURFOP-SI ALL WORK N ACt:ORD&NCE wriH SAN)OAt? qs ORDLSA.NCES.STATE LAWS AND <br /> PI <br /> R:'�A.`�D RECR:LATIONS OF SAN)UAWN CtX-%-,-y?UHL1 -F E :ri SERVICES OWN C'R LtCtNSE: AGEv",'c <br /> SIGNATLtRE CERTFW THE G -1 CERTIFY THAT IN THE P ANCE OF 7rfE'WORK FOR*MCH TrUS PEP IIT <br /> IS ISSLT.-D.I SHALL NOT EMPLOY ANY PEItSON IN SLICH A NtANNER AS TO BECOME SUBJECT TO WORKERS COMPENSATION <br /> LAWS u-CAr.�:rr2'a:f: CON-FiAC-1 MS e M,4.1 CdR SLIER U%CR.A-""TL►WG SIGNA VRE CER I T-!c3 THE Fa LLOW NG: 'I <br /> CERTjFyTjjATNTjMpEpMRMAtOF THE WORK FOR WHICH THIS PERMS!IS LSSLEDA SHALL EJrII'1.OY PERSONS <br /> SUBJECT TO WORKERS COMPENSATION LAW OF CAUF(V.NIA.' _ <br /> 4PPLIC.4'`'f S �I(iti 4Th tRL lT?7.� "� •� D e?=' t 1 O <br /> EH 23 046(REV 7110192) <br /> •J <br /> 3 <br />