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BILLING_PRE 2019
Environmental Health - Public
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EHD Program Facility Records by Street Name
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B
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BENJAMIN HOLT
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3011
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2300 - Underground Storage Tank Program
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PR0231883
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BILLING_PRE 2019
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Entry Properties
Last modified
9/25/2019 9:18:52 AM
Creation date
11/8/2018 10:23:52 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
BILLING
FileName_PostFix
PRE 2019
RECORD_ID
PR0231883
PE
2351
FACILITY_ID
FA0002111
FACILITY_NAME
BEN HOLT SHELL
STREET_NUMBER
3011
Direction
W
STREET_NAME
BENJAMIN HOLT
STREET_TYPE
DR
City
STOCKTON
Zip
95219
APN
10018010
CURRENT_STATUS
02
SITE_LOCATION
3011 W BENJAMIN HOLT DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Supplemental fields
FilePath
\MIGRATIONS3\B\BENJAMIN HOLT\3011\PR0231883\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
12/29/2011 8:00:00 AM
QuestysRecordID
104119
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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SVWI <br /> STATEOFCAUFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILRYlSITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT &5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 98 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /V <br /> DSAARFACILITYE ¢ �5 NAME OF OPERATOR <br /> KESS NEAREST CROSS STREET PARCEL#(OPrC*AL) <br /> fit/ 2rncn 13r�"vim 1-S <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> K� ca <br /> v BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR Q ,/ IF INDIAN #OFT T SITE E.P.A. L D.#(apfimeD <br /> RESERVATION <br /> a 3 FARM O d PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE--7 AYS:NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OFAgOFESS INFORM/ATION iA �7 4)w- 1 <br /> MAILI R TREET RESS ✓&oTn NtlkaM/n Q�I ,•NDNO-A'DULL /C3 LOCAL-AGENCYQ STATE-AGENCY <br /> • Dz Q CORPORATION Q PARTNERSHIP Q COUNTY'AGENCY Q FEDERAL AGENCY <br /> CITY NAlff STATSZIP CODE PHONE#WITH AREA CODE <br /> C0 deL4 <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) (//+/�/ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EW 0-*- Q INDIVIDUAL Q LOCAL-AGENCY Q STATE'AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNrY-AGENCY Q FEDERAUAGEWY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ a -- 0 0 0 0 <br /> V. PETROLEUM UST FINANCle RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓yayn 1 SEUNNSURED 0 2 GUARANTEE Q 3 INSURANCE Q I SURETYBOND <br /> S LETTER OF CREDIT Q a EXEMPRON Q 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD eE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. B III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY qw4t- JURISDICTION# FACILITY# <br /> �W L/a/D 67 30 F Q I <br /> LOCATION CODE- TONAL CENSUS TRACCT# I� NAL SUPVISOR-OISTMCT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LLEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION bNLY. <br /> FORM A(5-91) FOND=A-5 <br />
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