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BILLING_PRE 2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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C
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CLUFF
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2300 - Underground Storage Tank Program
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PR0231969
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BILLING_PRE 2019
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Entry Properties
Last modified
3/11/2021 11:03:29 AM
Creation date
11/2/2018 5:34:54 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0231969
PE
2381
FACILITY_ID
FA0003842
FACILITY_NAME
LODI USD-TRANSPORATION*
STREET_NUMBER
820
Direction
S
STREET_NAME
CLUFF
STREET_TYPE
AVE
City
LODI
Zip
95240
APN
04931030
CURRENT_STATUS
02
SITE_LOCATION
820 S CLUFF AVE
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\C\CLUFF\820\PR0231969\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
11/1/2012 8:00:00 AM
QuestysRecordID
138802
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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\� \� Gbh' l' <br /> STATE OF CAUFORMA ' <br /> STATE WATER RESOURCES CONTROL BOARD W a A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A >, ,, <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE `'a�•ae�" <br /> MARK ONLY F--j 1 NEW PERMIT F-1 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E:] T PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 0 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITY NAME NAME OF OPERATOR <br /> . S•�- <br /> ADDRESS NEAR ST CROSS STREET PARCELII(OPIIDMU <br /> y� S ;94s-;- R <br /> CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> Goan <br /> CAI 9SG o ( -5 71 <br /> .1 Box <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP (] LOCAL-AGENCY 0 COUNTYAGENCY' STATE-AGENCY' FEDEML-AGENCY' <br /> DISTRICTS' <br /> •N awcer o1 UST Is a public agency,cenpMte the IceoWing:name of Supervisor of tlNlabn,section,w office which operates the UST <br /> TYPE OF BUSINESS Q i GASSTATION Q 2 DISTRIBUTOR / <br /> IF INDDIAN a OF TANK AT SITE E.P.A. I.D.a rapNmap <br /> 3 FARM Q 4 PROCESSOR Ij 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME( T.FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> / 3 —�� <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.F IRST) PHONE 11 WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G• v- S. <br /> MAILING OR STREET ADDRESS — d^ ✓E9ebintlbale INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �.fi- /• S% O CORPORATION O PARTNERSHIP UNfYAGENCY L—I FEDERALAGENCY <br /> CITY NAME STATE. ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Cv. < . <br /> MAILING OR STREET ADDRESS ✓ box bbdbale (] INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> lei, O CORPORATION (] PARTNERSHIP I=COUNTYAGENCY M FEDERALAGENCY <br /> CI NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 45�w 7- /A <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓h�F bYtlbW 0 I SELF-INSURED D 2 GUARANTEE 3INSURANCE O 4 SURETY BOND <br /> L-1 5 LETTEROFCREDIT S EXEMPTION (] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q II. 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION# FACILITY# <br /> I I I / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a� Q 3L� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FORMM-R7 <br />
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