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BILLING 2007 - 2015
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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MCKINLEY
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16888
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2300 - Underground Storage Tank Program
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PR0232523
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BILLING 2007 - 2015
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Entry Properties
Last modified
12/7/2023 3:16:07 PM
Creation date
11/7/2018 6:59:47 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
2007 - 2015
RECORD_ID
PR0232523
PE
2361
FACILITY_ID
FA0003833
STREET_NUMBER
16888
STREET_NAME
MCKINLEY
STREET_TYPE
Ave
City
Lathrop
Zip
95330
CURRENT_STATUS
01
SITE_LOCATION
16888 McKinley Ave
P_LOCATION
07
P_DISTRICT
003
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\M\MCKINLEY\16888\PR0232523\BILLING 2007 - 2015 .PDF
QuestysFileName
BILLING 2007 - 2015
QuestysRecordDate
3/14/2017 6:05:19 PM
QuestysRecordID
3352980
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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� s <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone (209) 468-3420 Fax(209) 468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: uper Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 16888 McKinley Ave Lathrolp, CA ❑ Change of Designated Operator <br /> Facility Phone#: 209-858-3384 O Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: XeV=,— Relation to UST Facility(Check One) <br /> Business Name(1fdii erentfrom above) ❑ Owner )b Operator ❑ Employee <br /> Designated Operator's Phone#: 2nq_ _ jg4 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 O Nona! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(if diiferentfmm above): ❑ Owner V Operator ❑ Employee <br /> Designated Operator's Phone#: 209-858-3384 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opliona!) <br /> Designated Operator's Name: ath Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from ove): ❑ Owner jh Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Sp.Wrr�� Store Industries <br /> SIGNATURE OF TANK OWNER: �,.fti <br /> DATE: 12, — 9^ 0 9 OWNER'S PHONE#: (209) 858-3384 <br /> November 2004 <br />
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