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COMPLIANCE INFO_2013-2018
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0231876
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COMPLIANCE INFO_2013-2018
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Last modified
11/16/2023 11:39:52 AM
Creation date
6/3/2020 9:54:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2013-2018
RECORD_ID
PR0231876
PE
2361
FACILITY_ID
FA0000421
FACILITY_NAME
DINO MART
STREET_NUMBER
1001
Direction
E
STREET_NAME
YOSEMITE
STREET_TYPE
AVE
City
MANTECA
Zip
95336
CURRENT_STATUS
01
SITE_LOCATION
1001 E YOSEMITE AVE
P_LOCATION
04
P_DISTRICT
003
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231876_1001 E YOSEMITE_2013-2018.tif
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EHD - Public
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San Joaquin County <br /> Environmental Health Department <br /> 600 E.Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(2 09)468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: MCA f Facility ID#: <br /> Facility Address. Reason for Submitting this Form(Check One) <br /> Ma in te-ca '75; 12k G "ange of Designated Operator <br /> Facility Phone#: S— 11 c;ee 0 Update Certificate Expiration Date <br /> Designated UST Or&rator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: t Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom�above): 0 Owner 0 Operator 11 Employee <br /> Designated Operator's Phone#: a 0�— 8 RCS—LI 4G (0 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1(QpdonaO <br /> Designated Operator's Name:aaran 0- bkillm Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): Quick cto )Ma& o owner o operator 13 Employee <br /> Designated Operator's Phone#: a(n— e)—C.� 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 fflpdonaf) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 11 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): <br /> SIGNATURE OF TANK OWNER: IrWA" <br /> DATE: 01114 L3 —OWNEWS PHONE#: M1 :3 Z-2 ® 6e?i 3 <br /> T-T <br /> November 2004 <br />
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