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Pace 5 CALIFORNIA ENVIRONNMNTAL State of California « = 5 PROTECTION AGENCY,, PE Regional Water Quality Control Board APPLICATION/REPORT OF WASTE DISCHARGE GENERAL INFORMATION FORM FOR "4 - WASTE DISCHARGE REQUIREMENTS OR NPDES PERMIT A. Facility: I• FACILITY INFORMATION Name: Speedy Food #2. Address: ' 8200 N. Highway99 Ci-t: County: State: Zip Code: Stockton Aan Joaqui CA 95212 Contact Person: Telephone Number: 466-Q433 B. Facility Owner: Name: - Owner Type (Check Cne) Tuleburg Warehouse L ❑ individml 2. ❑ corpora=-Cn Address: 3. ❑ Governmental 4. Par`_ner. [p 301 S . Auxora Street Agency City: State: Zip Code: S. ❑ Other: Stockton CA 95203 LContact Perscn: - Telephone Number: Federal Tax i7: Ra Ba lietto { 09 )466-0433 C. Facility Operator (The agency or business,not the person): Name: Operator Type (Check One) :urrent S eedy Food Storei ® 2. E]individual Corl.crat_cn )para= 1 s not Address: ,. 3. ❑ Governmental 4. ❑ Parr-st-p 82()a N. H1 hWa 99 Agency A•p• C'_cy: - State: Zip Code: Stockton CA 95212 S. ❑ Other: Contact Person: - Telephone NU--her: Ab Nawar 209 931-0274 D. Owner of the Land: Name: Owner Type (Check One) 1. ❑ Individual 2. ❑ Co_•'=cration u dba Tu ebur War Ouse Adh'ress: -3. ❑ Governmental 4. ❑ Par'-•tee=s=p 101 S - AurQrn Strppt Agency C=my: State: Zip Code: Stockton CA 95203 5. ❑ other: Cc.tact Person: Telephone Number: Ray Ba lietto 209 466-0433 E. Address Where Legal Notice May Be Served: Address: Inj S . AUrQra Street Ci-f: State: Zip Code: Stockton CA 95203 Contact Person: Telephone Number• Ray R 20 466-0433 R Billing Address: Address: 301 S . Aurora Street _ C:='zState: Zip Code: Stockton CA 95203 Contact Person: Telephone Number: Ray Ba . ( 209) 465-0431 F.