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STATE OF CALIFORNrg WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ( FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 LY CLOSED SITE L-1 <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE NQ <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w <br /> Port of Stockton Food Dist . Inc . Randy Thomas 00 <br /> ADDRESS NEAREST CROSS STREET ..✓.Bwbii ❑ PAi1NEPBIW ❑ IT,1TE.1GBILY <br /> 2001 E . Fremont q ' : COWOR.noN ❑ FOCk AGPO 0 ROEI+AI.ACEac <br /> 0 INDNIDUa 0 =111YAGENDY <br /> CITY NAME STATE ZIP CODE SITE PHONE Al,WITH AREA CODE <br /> Stockton CA 95205 209-948-1814 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or If of TANICt <br /> ❑ 1 GAS STATION ❑3 FARM X❑ 5 OTHER TRUST LANDS ❑ C A C O O O S 2 7 6 O 8 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IFST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Thomas Rand 209-948-1814 <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> Thomas Rand 209-467-3266 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Port of Stockton Food Dist . Inc . <br /> MAILING or STREET ADDRESS Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> PO BOX 30 <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N.WITH AREA CODE <br /> Stockton CA 95201 209-948- 1814 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Port of Stockton Food Dist . Inc . <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> PO BOX 30 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE <br /> Stockton CA 95201 209-948-1814 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. © III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGDATE <br /> NAT <br /> Randy Thomas 6 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY* FACILITY ID B B of TANKS N SITE <br /> old I=p 7 h U o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER ( �PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TMCTN SUPERVISOR-)DISTR'IJC,T CODE BUSINESS PLAN FILED DATE FILED <br /> YES NOTi <br /> IC`s\ CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> \�\ THIS FORM MUST BE ACCOMPANIED BY AT LEAAT(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI 'INLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> `\ FORM A(3-2-BB) <br /> •\`vv�Y`1 ~`- DATA PROCESSING COPY ,� <br />