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BILLING_PRE 2019
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2300 - Underground Storage Tank Program
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PR0516736
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BILLING_PRE 2019
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Last modified
1/4/2023 4:19:21 PM
Creation date
11/2/2018 6:50:53 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0516736
PE
2361
FACILITY_ID
FA0012764
FACILITY_NAME
SAFEWAY FUEL CENTER #1769
STREET_NUMBER
2802
STREET_NAME
COUNTRY CLUB
STREET_TYPE
BLVD
City
STOCKTON
Zip
95204
CURRENT_STATUS
01
SITE_LOCATION
2802 COUNTRY CLUB BLVD
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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SJGOV\rtan
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FilePath
\MIGRATIONS\C\COUNTRY CLUB\2802\PR0516736\BILLING 2001-2006.PDF
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EHD - Public
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Formerly SWRCB Form B UST - Tank Page 2 <br /> (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data <br /> element numbers are used for electronic submission and are the same as the numbering used in 27 CCR, Appendix C, <br /> the Business Section of the Unified Program Data Dictionary.) <br /> Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is <br /> complete and if any pages are separated. <br /> 458. PIPING SYSTEM TYPE (UNDERGROUND) - For items 458 and 459, check the tank=s piping system <br /> 459. PIPING SYSTEM TYPE (ABOVEGROUND) information. CHECK ALL THAT APPLY. <br /> 460 PIPING CONSTRUCTION (UNDERGROUND) - Check the tank=s piping construction information. CHECK ALL <br /> THAT APPLY. <br /> 461. PIPING MANUFACTURER (UNDERGROUND) - Enter the name of the piping manufacturer. <br /> 462. PIPING CONSTRUCTION (ABOVEGROUND) - Check the tank=s piping construction information. CHECK ALL <br /> THAT APPLY. <br /> 463. PIPING MANUFACTURER (ABOVEGROUND) - Enter the name of the piping manufacturer. <br /> 464. PIPING MATERIAL AND CORROSION PROTECTION (UNDERGROUND) - For items 464 and 465, check the <br /> 465. PIPING MATERIAL AND CORROSION PROTECTION (ABOVEGROUND) tank=s piping material and corrosion <br /> protection. <br /> 466. PIPING LEAK DETECTION (UNDERGROUND) - For items 466 and 467, check the leak detection system(s) used <br /> 467. PIPING LEAK DETECTION (ABOVEGROUND) to comply with the monitoring requirements for the piping. <br /> 468. DATE DISPENSER CONTAINMENT INSTALLED - If applicable, enter the date that dispenser containment was <br /> installed. <br /> 469. DISPENSER CONTAINMENT TYPE - Check the type of dispenser containment monitoring system. <br /> SIGNATURE OF OWNER/OPERATOR -The owner or agent of the owner shall sign in the space provided. This <br /> signature certifies that the signer believes that all the information submitted is true and accurate. <br /> 470. DATE CERTIFIED - Enter the date the page was signed. <br /> 471. OWNER/ OPERATOR NAME - Print the name of signatory. <br /> 472. OWNER/OPERATOR TITLE - Enter the title of the person signing the page. <br /> 473. PERMIT NUMBER - Leave this blank, this number is assigned by the CUPA. <br /> 474. PERMIT APPROVED BY - Leave this blank, this is the name of the person approving the permit. <br /> 475. PERMIT EXPIRATION DATE - Leave this blank, this is completed by the CUPA. <br />
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