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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z` °� ' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��.o�.> <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ®7 PERM OSEDSITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> OD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Port of Stockton Food Dist . Inc . Randy Thomas Op <br /> ADDRESS NEAREST CROSS STREET ..✓.Sale ule ❑ PWaNBIRIP ❑ SIATEAGDO <br /> 1950 E . Miner Ave ' A ' oo ro nON ❑ Loch AGDO ❑ RDERAL ACENDY <br /> ❑ INDMIDUk ❑ WUNTY-AGENCY <br /> CITY NAME STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> Stockton CA 95205 209-948-1814 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION orCAC 0 0 0 5 2 7 61 6 *01 TMWS <br /> TRUST LANDS ❑ AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> Thomas , Randy 209-948-1814 <br /> NIGHTS: NAME(LAST,RRST) PHONE k WITH AREA ODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Thomas , Randy 209-467-3266 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Port of Stockton Food Dist . Inc . <br /> I <br /> MAILING or STREET ADDRESS .✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> PO BOX 30 ❑] INDIIVIDUALION El COUNTY AGENCY 1-1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> Stockton CA 1 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 ADDRESSv✓Box to indicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> PO BOX 30 �] CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ OUNTV-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE a,WITH AREA ODE <br /> Stockton CA 95201 209-948-1814 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE AD BUS$$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. X❑ 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 8 SIGNATURE) DATE <br /> Randy Thomas <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION M AGENCYN, FACILITY ID If If of TANKS at SITE <br /> 3 9 d C) I, O o d <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE a WITH AREA CODE <br /> oK4-S 1 <br /> PERMTTNUMBER IPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 0 LOCATION CODE CENSUS TRACQTa SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Q� O D 3 ]- 3 YES � NO 10'G6 -fo <br />\ CHECK* PERMRAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> wIeS I \ <br /> THIS FORM MAST BE ACCOMPANIED BY AT LEAs ','1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S1 I INLESS THIS IS A C ANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88t <br /> DATA PROCESSING COPY <br />