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eyou• � <br /> STATE OFCALIFORNIA �O+ <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� n s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Vincent Re noso Concrete Const . Co. Vincent Re noso <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPrONAW <br /> 729 So. Commerce St <br /> CIN NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> Stockton CA 95203 40 <br /> TO INDICATE O CORPORATION moi(INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 0 COUKrY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 OAS STATION ❑ Ad DISTRIBUTOR 0 ✓ IF INDIAN 4 OF TANKS AT SITE E-P.A. I.D.a(optimal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Reynoso, Vincent 209-464-0840 <br /> NIGHTS: NAME(LAST,FIRS1) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Clarke, Fredrick 707-255-8031 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Fredrick D . Clarke <br /> MAILING OR STREET ADDRESS ✓ bDMbIWICm n INDIVIDUAL <br /> O LOCAL-AGENCY O 9TATE-AGENCY <br /> 352 Deer Hollow O CORPORATION = PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> Napa CA 94558 707-255-8031 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Fredrick D. Clarke <br /> MAILING OR STREET ADDRESS ✓baa bhwka INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 352 Deer Hollow O CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Napa CA 1 94558 707-255-8031 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ [-4T4-1- b 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkata Q 1 SELFINSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY" <br /> 5 LETTEROFCREDIT O 6 EXEMPTION X] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL® III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) <br /> APP ICANTS TITLE DATE MONTWDAVNEAR <br /> ke <br /> Fredrick C . Clar - er 12/5/91 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY# <br /> 3 as <br /> LOCATION CODE -OPTIONAL CENSUSTRACT -OPTIONAL SUPVISOR-DISTRICT CODE - IOAIAL <br /> 3 .23 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OA MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) " W C ` S FORMA5 <br />