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BILLING_PRE 2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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EL DORADO
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2300 - Underground Storage Tank Program
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PR0331843
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BILLING_PRE 2019
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Entry Properties
Last modified
3/28/2021 10:35:13 PM
Creation date
11/4/2018 4:26:28 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0331843
PE
2381
FACILITY_ID
FA0003542
FACILITY_NAME
ALLIANCE
STREET_NUMBER
8750
Direction
S
STREET_NAME
EL DORADO
STREET_TYPE
ST
City
FRENCH CAMP
Zip
95231
APN
19314001
CURRENT_STATUS
02
SITE_LOCATION
8750 S EL DORADO ST
P_LOCATION
99
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\E\EL DORADO\8750\PR0331843\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
12/17/2012 8:00:00 AM
QuestysRecordID
79137
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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STATE OF CALIFORNIA-- WATER RESOURCES CONTROC4OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE -4 <br /> Cil <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C <br /> FACILITY/ IT NAME CARE OF ADDRESS INFORMATION <br /> I cote e "-k es <br /> ADDRESS NEAREST CROSS STREET ✓Bmroidkak Cl PARTNERSHIP 0 STATE AGI <br /> 0CORPORATION 0 LOCAL-AGENCY 0 FEDEWAG90 <br /> Do q 0 /-N Atw— INDmowL ❑ 10An -AGD+a <br /> CITY NAME STATE ACODE SITE PHONE N.WITH AREA CODE <br /> F-rewd.. CA Llrz 4 <br /> If TYPE OF BUSINESS: ❑p DISTRIBUTOR flOCES50fl ✓Box if INDIAN EPA ID N <br /> RESERVATION or Aof HIS SI <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE 5 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) AA7j PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> N. Thl ' � --.-77i" <br /> NIGHTS: NAME(LAST,FIRST) PjjONE#WLTH AREA&DE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �/ / <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I N e- <br /> MAILINGorSTREETADDRESS ✓ to indicate ❑ PARTNERSHIP 0 STATE AGENCY <br /> O_ INDIVIDUAL <br /> 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 13� 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> Ievcpk 170 -?9;L-^ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sam 'i <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL'-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <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.e 111. ❑ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY b JURISDICTION N AGENCY M FACILITY ID It If o/TANKS at SITE <br /> ® 3 <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE IF WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DDAAT FILE J, <br /> -3,-an 3S YES [-] E:] O NO d/ <br /> CHEC • PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONS), UNLESS THIS IS A CHANGE OF SITE INFORMATIONON ONLY <br /> ORM A(3-2-81ir} <br /> DATA PROCESSING COPY a/ <br />
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