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COMPLIANCE INFO_1986-1997
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2300 - Underground Storage Tank Program
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PR0231766
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COMPLIANCE INFO_1986-1997
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Last modified
11/21/2023 3:55:24 PM
Creation date
6/3/2020 9:52:47 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1986-1997
RECORD_ID
PR0231766
PE
2361
FACILITY_ID
FA0003717
FACILITY_NAME
CHEVRON STATION #99840*
STREET_NUMBER
4344
Direction
E
STREET_NAME
WATERLOO
STREET_TYPE
Rd
City
Stockton
Zip
95215
APN
10102156
CURRENT_STATUS
01
SITE_LOCATION
4344 E Waterloo Rd
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231766_4344 E WATERLOO_1986-1997.tif
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EHD - Public
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INSTRUCTIONS <br /> "A" <br /> GENERAL INSTRUCTIONS: <br /> � v <br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CO'DF OF REGULATIONS TO <br /> SECTIONS 25286,25287,AND 25289 OF CHAPTER <br /> 6.7,DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE REQUIRE OWNERS"IO APPLY FOR AN UST OPERATING PERMIT. <br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES, <br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the slumber of tanks located at the site. <br /> 3. This form should be completed by either the;PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. <br /> 4. Please type or print clearly all requested information. <br /> 5. Use a hard point writing instrument;you are making 3 copies. <br /> 6. Tank owner must submit a facility-plot plan to the local a r ncy as part of the application showing the location of the USTs with respect to <br /> buildings and landmarks[Section 2711(a)(8),LCR). <br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the <br /> application for petroleum USTs[Section 2711(a)(I1),CCR). <br /> TOP OF FORM:"MARK ONLY ONE ITEM" <br /> Mark an(X)in the box next to the item that hest describes the reason the:form is being completed. <br /> I. FACILITY/SITE INFORMATION$ADDRESS(MUST BE COMPLETED) <br /> 1. Record name and address(physical location)of the underground tank(s). <br /> MOTE: Address MUST have a valid physical location including city,state,and zip code. <br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE. ` <br /> Iiclude neatest cross street and name of the operator. „ <br /> 2. Phone number must have an area code. If the night number is the same,Iwrite"SAME"in proper location. <br /> 3. Check the appropriate bora for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.), <br /> 4. Check the appropriate box for TYPE OF BUSINESS, � <br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES„ <br /> 6. Indicate the NUMBER of TANKS at this SITE, <br /> 7. Record the 1,P,A.ID#P or write"NONE"in the space provided. <br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) <br /> Conalalete all iterns in this section,unless all items are the same as SECTION 1:If the same,write"SAME AS SITE"across this section. Be scare <br /> to check PROPERTY OWNERSHIP TYPE box, <br /> III.TAMC OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) <br /> Complete all items in this section,unless all items are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure <br /> to cheek TANK OWNERS TYPE box. <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75, <br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY COLE.) <br /> Enter your hoard of Equalization(BOE)LIST storage fee account number which is required before your permit application can be processed. <br /> Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the per gallon fee due on the number of <br /> gallons placed in your LSTs. The.BOB will code persons exempt from paying the storage fee;so returns will not be sent. If you do not have an <br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the <br /> BOB at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR.PETROLEUM-USTs ONLY,SEE SECTIONS 2711(a)(11) <br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.) <br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.USTs owned by <br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement. <br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS <br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIOItiS. a <br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED, [SEE SECTIONS 2711 <br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.) <br /> INSTRUCTION FOR THELOCALAGENCIES <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may <br /> be assigned by the local agency,however,this number must be numerical and cannot contain any alphabetical characters. If the local agency <br /> prefers the State Board to assign the facility number,please leave it blank. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL. <br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF T14E "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL <br /> AGENCY SHOULD RETAIN THE ORIGINAL AND FELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK <br /> OWNER. <br />
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