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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE -r-f <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSUREFM .0 <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 Op <br /> ADDRESS NEAREST CROSSSTREET .gmb-nGraa ❑ PABRIENSHIP ❑ VATEAGENCY <br /> 2040 E . Fremont A ' Street PATION 0 LOMMENC/ Cl FMPAL GENLY <br /> ❑ INDIYDUAL ❑ CCUNFYAGEND <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> Stockton CA 95205 209-948- 1814 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -✓BO%if INDor #of TANK'#IAN EPA ID# <br /> ❑ 7GAS STATION 3FARM ® SOTHER TRUST LANDS CACCO0527624 ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Thomas , Randy 209-948-1814 <br /> NIGHTS'. NAME(LAST,FIRST) PHONE B WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N 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 /> MAILING or STREET ADDRESS . Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> PO BOX 30 7`d CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#,WITH AREA CODE <br /> Stockton CA 95205 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 ❑ STATE-AGENCY <br /> PO BOX 30A CORPORATION <br /> OCORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Stockton CA 95205 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. XQ 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&SIGNATURE DATE <br /> Randy Thomas �� g <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# a of TANKS at SITE <br /> d d I ) v lololol <br /> CURRENT LOCAL AGENCY FACILITY IO N APPROVED BY NAME PHONE#WITH AREA CODE <br /> of ,fa0 <br /> PERMIT NUMBER r PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> OCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0/ z3 fa ) 2 YES NO 1d-7'6 -,7d <br /> �` \\[ICIHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:/ <br /> \\�U THIS FORM MUST BE ACCOMPANIED BY AT LFAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION01, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. A� <br /> FOAM A(3-2-SS) <br /> `—DATA PROCESSING COPY �'^i <br />