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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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PR0232403
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BILLING_PRE 2019
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Entry Properties
Last modified
3/11/2021 1:39:57 PM
Creation date
11/5/2018 11:20:49 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0232403
PE
2381
FACILITY_ID
FA0009790
FACILITY_NAME
CITY OF STOCKTON FIRE STATION #7
STREET_NUMBER
1767
Direction
W
STREET_NAME
HAMMER
STREET_TYPE
LN
City
STOCKTON
Zip
95209
APN
07509036
CURRENT_STATUS
02
SITE_LOCATION
1767 W HAMMER LN
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\H\HAMMER\1767\PR0232403\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
5/9/2013 8:00:00 AM
QuestysRecordID
163344
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBApgFACILRY NAME N OF ERATOR <br /> nai <br /> ADDRRE <br /> m NE ES C SSS E P -EI a(OPrpNAU <br /> CI / <br /> STA ZIP SITE PHONE S WITH AREA CODE <br /> CA <br /> IOX <br /> T NOCATE I1 CORPORATION INDIVIDUAL E:I PARTNERSHIP O LOCAL-AGENCY ED COUNTY-AGENCY• a STATE-AGENCY' O FEDERALAGENCY' <br /> •N cater d UST is a public DISTRICTS' <br /> p aeenq,csmplela iM topowlnp:nazre b Supervisor of Eiviion,section.W office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANK qT SITE E.P.A. I.D.A(cpnwwJ <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q a OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIfl3T) PHONEi WITH AREA CO DE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmbin*AW D INDIVIDUAL 0 LOCAL-AGENCY 0 STATEAGENCY <br /> V V •' — O CORPORATION [:j PARTNERSHIP ED COUNTY-AGENCY 0 FEDEML-AGENCY <br /> STAT <br /> CITY NAME E ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓buthdkes INDIVIDUAL E-1 LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION E2 PARTNERSHIP COURTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHO NE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIALRESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓bos biMbaN 0 ELF-INSURED I� 2 GUARANTEE Q URANCE A SURETY BOND <br /> S LETTER)F CREDIT E--1 6 EXEMPTION 6e OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICHABOVE ADDRESSSHOULDBE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 6 JURISDICTION JF FACILITY x <br /> � P� C �� 9qI <br /> LOCATION CODE -OPTIOL L CENSUST iT. SUPVISOR-DISTRI'g /M 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS tHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) FORIXDYIAI <br />
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