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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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PR0503585
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BILLING_PRE 2019
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Entry Properties
Last modified
3/23/2021 12:04:19 AM
Creation date
11/6/2018 10:09:43 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0503585
PE
2332
FACILITY_ID
FA0005888
FACILITY_NAME
CHESTER MEYER RESIDENCE
STREET_NUMBER
32
Direction
W
STREET_NAME
PARK
STREET_TYPE
ST
City
STOCKTON
Zip
95202
CURRENT_STATUS
02
SITE_LOCATION
32 W PARK ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\P\PARK\32\PR0503585\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
10/17/2017 5:35:32 PM
QuestysRecordID
3685035
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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v` <br /> A01rSTATE OF CALIFORNIA ^e ec}ouR C ei <br /> '\ STATE WATER RESOURCES CONTROL BOARD g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> C�(,I'OI,N•e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY- 0 1 NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DNFACILIJYNAME NAMEOF OPERATOR <br /> e5jr.r Meyer - residinU- <br /> ADDR 3 NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> 2 W . Pair►' strzr <br /> CITY NAM STATE ZIP CODfq-��� SITE PHONE#WITH AREACODE <br /> 3o <br /> CA //y/ /UJ/i,/p_ `IY/ 7/1 <br /> ✓ BOX <br /> TO INDICATE D CORPORATION O INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opt/mal) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILIN RSTREET DRESS pyo / ✓box b Indicate INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> n-Q� CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAM STATE^ ZIP C�E PHONE#_WITH AREA CODE O�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /l//T <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0IMIcau 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP ED COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 7441- <br /> ©3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate O 1 SELF-INSUREDQ GUARANTEE O 3 INSURANCE D A SURETY BOND <br /> O 5 LETTER OF CREDIT 6 EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® �eyea <br /> LOCATION CODE -OPTIONAL TRACT# -OPt #2,xL SUPVISOR-DISTRICT CODE -OP <br /> Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE <br /> /O�Fr-SITE INFORMATION ONLY. <br /> FORM A(5-91) ///Ir <br /> FORW/33A5� <br />
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