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Eh°UR �S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDF o <br /> DERGROWD STORAGE TANK PERMIT APPLICATI0- FORM A W <br /> a <br /> hil, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> '1 <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT t75 CHANGE OF INFORMATION 7 PERMANENT E <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> LAWRENCE LIVERMORE NATIONAL ABORATOY RY <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TRArY CA 95376 (51-0) 493-5386 <br /> TO <br /> I/ BICO TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = 1 GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION ►OF TANKS AT SITE E.P.A.pL(]O.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR [:X 5 OTHER OR TRUST LANDS 3 A2890090002 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGEN CONTA SON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> SFTTI-Fj BOR (510)422-0791. <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY EX FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> 0 510)422-0791 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> LAwRENg IVERMORE NATIONAL LABORA -_ BOR SETTIE <br /> MAILING OR STREET ADDRESS �^ ^ ✓ box b indiam Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q <br /> h0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA 9455 (510)422-0791 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4747- <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q ".;K III.F <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRNTED 1 SK)NATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> PROJECT MANAGER <br /> LOCAL AGENCY USE ONLY <br /> �tRtnB JURISDICTION# <br /> ... � (fF�JACI)L(rrY# <br /> 6 <br /> il <br /> k��yIr <br /> 11 Y?r <br /> LOCATION IKJNAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -3Z <br /> THIS FORM 0'"""AMWAWD At X111111 dR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A it I" r FOR0033A-R2 <br />