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L�FORNI WATER RESOURCES CONTROL BOAR r/• � STATE OF CA D FORM `A': u UNDERGROUND STORAGE TANK PROGRAM � �a SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z COMPLETE THIS FORM FOR EA TY/SITE FMARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHAN F INFORMATION 7 PERMA OSED SITE IV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE y rV I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) f7� FACILITY/SITE NAME CARE OF ADDRESS INFORMATION FAIRGROUNDS INDUSTRIAL PARK ADDRESS NEAREST CROSS STREET ✓Bar to iII Cl PARTNERSHIP ❑ STATE-AGENCY 1250 SOUTH WILSON WAY EAST CHARTER WA ❑ CORPORTOLOX-AGENCY13 FEDERB LO CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE STOCKTON CA 95205 209-462-8538 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID # If of TANK's RESERVATION or AT THIS SITE 3 ❑ 1 GAS STATION ❑ 3 FARM X❑ S OTHER TRUSTLANDS ❑ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE MORGAN, BOB 209-462-8538 LEVIN, SYDNEY 408-265-1444 NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE,WITH AREA CODE MORGAN BOB 209-477-7200 LEVIN, SYDNEY 408-269-3704 IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SYDNEY LEVIN MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 LOCAL-AGENCY 1530 MERIDIAN AVENUE, SUITE 108 ClNDIIVDUALION ❑ COUNTY-AGENCY ❑ FEDERAL-AGENC CITY NAME STATE ZIP CODE PHONE k WITH A4A CODE SAN JOSE, CA 95125 408-26 444 ° III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) �� IL CARE OF ADDRESS INFORMATION k�� a NAME SAME AS SITE MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑❑ CORPORATION ❑ LOCAL-AGENCY ❑M INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.W IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ® It. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. A PLICANT'SNAME(P INTED&SIGNATURE) DATE SYDNEY LEVIN 10/13/89 LOCAL AGEN Y U ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED O 3 7'2 YES E] NO C # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST' OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UQS THIS CHANGE OF SITE INFORMATION ONLY.(� `- OS 'FORM A(3-2-88) ✓\/1 •DATA PROCESSING COPY W)