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BILLING
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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S
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SHAW
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1282
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2300 - Underground Storage Tank Program
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PR0231726
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BILLING
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Entry Properties
Last modified
9/10/2024 2:58:08 PM
Creation date
11/6/2018 1:32:26 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
RECORD_ID
PR0231726
PE
2381
FACILITY_ID
FA0003759
FACILITY_NAME
ST&E Roundhouse
STREET_NUMBER
1282
STREET_NAME
SHAW
STREET_TYPE
Rd
City
Stockton
Zip
95215
APN
14327016
CURRENT_STATUS
02
SITE_LOCATION
1282 Shaw Rd
P_LOCATION
99
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\S\SHAW\1282\PR0231726\BILLING .PDF
QuestysFileName
BILLING
QuestysRecordDate
3/8/2017 7:22:57 PM
QuestysRecordID
3349696
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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# s <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD d d� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 1� 'o <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO 2 <br /> ;��t <br /> ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q_ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2r7- N• SN011/ 21011" EMdN� <br /> CITY NAME STATE ZIP CODE ITEPHONENWITH AREA CODE <br /> 574lalG� CA 96205 20q) - p0/ <br /> ✓BOX 5jrCORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGE14CY COUNTY-AGENCY' STATE-AGENCY' O FEDERAL--AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 <br /> me,N USTk a public agency,mmpWte the lolbwng:rare of supervisor cl division,WiDn"otricev ich opendes Na UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORgESVIFINDIAN ERVATION N OFTANKS AT SITE E.P.A I.D.N(optionaO <br /> ❑ 3 FARM ❑ 4 PROCESSOR CK 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) PHONE#WITH AREA CODE <br /> G4R�VEY c3BE 2og)ya-7co/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> Bnc✓Fav MEA2L/rV Zo9' q�Z-S/`fb <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V rr4V 454546W <br /> MAILING OR STREET ADDRESS .1 box to itdrate 0INDMDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> 13349 MOQT#N! B,20r¢DW�4Y 0 CORPORATION I]PARTNERSHIP COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE M WITH AREA CODE <br /> Srdc�Tv�✓ c�4 . 9szo5 Z� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S7&6,rra41 0 9444?.F9A <br /> MAILING OR STREET ADDRESS ✓ box to Indicate ED INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 1330 /tlOR-TH j9A20,1eA-11 y UCORPORATION I= PARTNERSHIP D COUNTY-AGENCY E:l FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE NEp WITH AREA CODE <br /> Srac�7at/ c,4 9sao5 HO )4SG6-loo/ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - D f� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 I SELF-INSURED O 2 GUARANTEE =31NSURANCE =4 SURETY BOND = 5 LETTEROFCREDIT = 6 EXEMPTION 7 STATEFUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 0990THER <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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ It ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNA ) TANKOWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCA AGENCY U ONLY 7 �;z <br /> COUNTY N JURISDICTION# FACILITY# <br /> FF <br /> LOCATION CODE •OPTIONAL CENSUa T N - 7rNAL SUPVISOR-DI I�COODE - TIONAL <br /> s C25•l4/1 <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 /> FORMA(6-96) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNTORAGE TANK REGULATIONS <br />
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