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COMPLIANCE INFO_1995
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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M
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MARCH
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2300 - Underground Storage Tank Program
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PR0231176
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COMPLIANCE INFO_1995
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Entry Properties
Last modified
6/10/2020 4:11:26 AM
Creation date
6/3/2020 9:45:50 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1995
RECORD_ID
PR0231176
PE
2361
FACILITY_ID
FA0003798
FACILITY_NAME
MARCH LANE 76*
STREET_NUMBER
2701
Direction
W
STREET_NAME
MARCH
STREET_TYPE
LN
City
STOCKTON
Zip
95219
APN
11619007
CURRENT_STATUS
01
SITE_LOCATION
2701 W MARCH LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231176_2701 W MARCH_1995.tif
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EHD - Public
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60UF p <br /> Pt . 00 <br /> STATE OF CALIFORNIA s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY CLOS S <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> -p <br /> V�0 L-A 1- S . S Its it g ��-'tom 0 P L.-L_ -- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S'T 0,.J CA 1S Hca 26-i) 1-I'13-'13 31 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 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 /> ,A MA!A-0o L►-r 1114 1 L4 G-7 2- -1 (o S 9 PHONE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> A rv-kAYb I L-.L l 1 -S -111-1 5'I 2--7 Iv 1i 9 PHONE#WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> lip Qe':�>nvLTs c. - cA6,-- u>JOcam.tr: <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> V-11 2-11 rE- I1Me�—_Y2_4 AL �4 h/ CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ES iz-1s ej, CA 't z-'I to I9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .01 to P2o1r�✓G. alba I,rJ OC-A L- <br /> MAILING OR STREET ADDRESS 'p ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 2L 2q 97. I VL'l r )/�L N y�/ (�CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> >�Z—C- (tea -C--i 2-L,2► � M)14)GnZ- _7L-Gj <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - O o 0 o G <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box toindicate 1 SELF-INSURED it 2 GUARANTEE E::] 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT =6 EXEMPTION = 99 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.F-1 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> Lv-i� LOQ d)1 t", AD .e,r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL _ <br /> IU I S <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrrE&fbRMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />
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