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COMPLIANCE INFO_1987-1998
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2300 - Underground Storage Tank Program
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PR0231989
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COMPLIANCE INFO_1987-1998
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Last modified
10/21/2022 4:24:09 PM
Creation date
6/23/2020 6:54:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1987-1998
RECORD_ID
PR0231989
PE
2361
FACILITY_ID
FA0003976
FACILITY_NAME
VALLEY PACIFIC CHARTER WAY CARDLOCK
STREET_NUMBER
1501
Direction
W
STREET_NAME
CHARTER
STREET_TYPE
WAY
City
STOCKTON
Zip
95206
APN
16337016
CURRENT_STATUS
01
SITE_LOCATION
1501 W CHARTER WAY
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231989_1501 W CHARTER_1987-1998.tif
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EHD - Public
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t go,+A <br /> STATE OFCAUFOR)<MA - ".••:p`- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> �— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY C I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED R <br /> ONE ITEM 2 INTERIM PERMIT Cj a AMENDED PERMIT s TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> IML <br /> i,Jpol e D�1 Ca ' 1®mak Waaf o�1 Z „c- <br /> ADDRESS ii ( NEAREST CROSS ST ET PARCEL I(OPTIONAL) <br /> O ) f.J t✓K0.1r t t <br /> CITY NAME STATE ZIP CODE ! SITE PHONE 9 WITH AREA CODE <br /> -fa ✓e i CA i r9SZofo (2BOX0 <br /> 7INDICATE CORPORATION Q INDIVIDUAL Cj PARTNERSFIIP Q LOCAL-AGENCY COUNTY AGENCY (_ STATE-AGENCY _ FEDERAL•AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS '- I GAS STATION2 DISTRIBUTOR ,/ IF INDIAN I#OF TANKS AT SITE E.P.A. I.0.s(opnonal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR ,< 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) (7-o qj) y q i,-9 y/Z <br /> _._ 91 Ort .ftp fto-j) 5 — /Z L,It,'1 ter J o <br /> NIGHTS: NAME(LAST,FIR T) PHONE A gWITH AREA CODE <br /> / NIGHTS: NAME(LAST,FIRST) (Zp ct) /y 8-55-3Z7 <br /> E! 1 4SOt1 Mike (ZOc'f 5z-3 .�O MWONE n VITP ARPA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /� p 1 CARE OF ADDRESS INFORMATION <br /> 42" 4 /9�GhLccrA Y�1 Aler-soro 1i oil lnc_ <br /> MAILING OR STREET ADDRESS Wes <br /> 4. 1 ✓ b*s b1 �INDIVWUAL LOCAL-AGENCY STATE-AGENCY <br /> IH t: r•ayi k W s `' C O V j oL-- I �CORPORATION PARTNErSSIMP 77 COUNTY.AGENcy FEDERAL-AGENCY <br /> CITY NAME f STATE ; ZIP CODE PHONE x WITH AREA CODE <br /> �fa h ! G)4 ! `7S-2 0(® c 2 ol s- YC L <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _--mac` � iG�lcaar c/ I9�'%'SOYo L✓®o{S ©t` ZMG <br /> MAILING OR STREET ADDRESS } ✓ 41notcMa INDIVIDUAL LCCA4AGENCY STATE-AGENCY <br /> CORPORATION C PARTNERSMP J COUNrY.AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE s WITH AREA CODE;j <br /> S+-dC. H (—A gsZ�W Czori) 5yg— lz <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 41 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ <br /> box toindicate I SELFdNSURED ^2 GUARANTEE J INSURANCE 4 SURETY BONO <br /> 5 LETTER OF CAEDIT 5 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 11 is checked. <br /> [CHECK ONE BOX iN01CATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND SILUNG: !. II.F— III. <br /> THIS FORM HAS BEEN COMPLEP NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PL:CANT'S NANIE;PRINTED&SIGNAP ) \ f/'. APPU S TITLE DATE MONTHiDAY.YcAR <br /> LOCAL AGENCY USE ONLY <br /> CCUNTY x JURISDICTION x FACILITY x <br /> t <br /> ,OCA"CV COBE P ONAL CENSUS TRACT s -OPTIONAL SUPVISCR-DISTRICT CODE -OPTIONAL <br /> THIS FORM%%UST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> _ca;A 2 9 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />
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