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BILLING_PRE 2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0231532
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BILLING_PRE 2019
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Entry Properties
Last modified
10/4/2022 2:28:59 PM
Creation date
11/2/2018 3:58:20 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0231532
PE
2351
FACILITY_ID
FA0000185
FACILITY_NAME
CITY FOOD & LIQUOR
STREET_NUMBER
16470
STREET_NAME
CAMBRIDGE
STREET_TYPE
ST
City
LATHROP
Zip
95330
APN
19643032
CURRENT_STATUS
03
SITE_LOCATION
16470 CAMBRIDGE ST
P_LOCATION
07
P_DISTRICT
003
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\C\CAMBRIDGE\16470\PR0231532\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
10/23/2012 8:00:00 AM
QuestysRecordID
132740
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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San Joaquin County Environmental Health <br /> 600 E. Main Street <br /> Stockton, Ca 95202-3029 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> And Understanding of and Compliance with UST Requirements <br /> Facility Name: Circle K Store#2701205 Facility ID#: <br /> Facility Address 16470 Cambridge Reason for Submitting this Form(Check One) <br /> Lathrop,Ca 95330 0 Change of Designated Operator <br /> Facility Phone#: 209-858-4116 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Rudolfo Tovar Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above):Same as Above ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: 530-681-0009 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5249165-UC 09/22/12 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Kevin Quinn Relation to UST Facility(Check One) <br /> Business Name Qfdierentfrom above):Same as Above ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#:559-647-6910 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5248754-UC Expiration Date:02/11/13 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks <br /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Trisha Yahner, Environmialtal Compliance Specialist <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 10/20/11 O R'S PHONE#: 951-270-5193 <br /> September 2004 <br />
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