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COMPLIANCE INFO_1996-2004
Environmental Health - Public
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2300 - Underground Storage Tank Program
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PR0231125
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COMPLIANCE INFO_1996-2004
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Last modified
5/24/2024 11:40:15 AM
Creation date
6/23/2020 6:43:31 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1996-2004
RECORD_ID
PR0231125
PE
2361
FACILITY_ID
FA0003730
FACILITY_NAME
TIWANA GAS & FOOD
STREET_NUMBER
1210
Direction
E
STREET_NAME
HAMMER
STREET_TYPE
LN
City
STOCKTON
Zip
95210
APN
09403012
CURRENT_STATUS
01
SITE_LOCATION
1210 E HAMMER LN
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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SJGOV\rtan
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\MIGRATIONS\UST\UST_2361_PR0231125_1210 E HAMMER_1996-2004.tif
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EHD - Public
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INSTRUCTIONS FOR COMPLF-IIING FORM W <br /> GIRNERAL INSI.'RLJ(.7I70NS: <br /> L One FORM "A" shall he completed for all NEW PERMITS,, PERMI'1`01ANGE-S or any FACII,rrYjsrw, <br /> INFORMN]ION CIIANGE& <br /> 1 SUBMIT' ONLY ONE (1) FORM W for a Facility/Site, regardless of the number of tanks locatcd <br /> 1. This form should be completed by either the IIIJRMTT APPLICANT"or the LOCAL AGENCY UNDFIRGROU',ND <br /> TANK INSPECIX)R. <br /> 4, Nease type or print clearly all requested information, <br /> 5. Use a bard point writing instrument, you are making 3 copies. <br /> JIOP Of?VIORM- 'MARK ONLY ONE ITEM" <br /> Mark an (X) in the box next to the item that best describes the reason the form is bcm- completed. <br /> INFORAMnON & ADDRESS(MUS-17 BE COMI'MMED) <br /> J., Record name and address (physjcal location) of the underground tank(s). <br /> NOTE: Address MIDST have a valid physical location including city, state, and zip code. <br /> P.O. BOX NUMBERS ARE NOT AM.FFABIJL <br /> Include nearest cross street and name of the operator. <br /> 2. Phone number must have an area code, If the night number is the same, write "SAME' in proper location. <br /> 1 Check the appropriate box far TYPE OF BUSINESS OWNERSHIP (ex, CORPORATION. INDIVIDUAL, cic.) <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 "YE-S.". <br /> 6. Indicate the NUMBER.of TANKS at this SITE. <br /> 7, Record the E.P.A. ID # or write "NONE" in the space provided. <br /> 11. PROPER`J'Y OWNER INFORMIVIION&ADDRF-SS (MUST BE COMPLHI-FD) <br /> Complete all items in this section, unless all items are the same as SEC'T'ION 1; if the same, write *SAME.AS S17170 aiross <br /> this section. Be sure to check PROPERTY OWNERSHIP "I:A'I'L box. <br /> 1,11, TANK OWNER INFO)RMA711ON &ADDRESS (MUST' 13F COMI` I1 3) <br /> Complete all items in this section, unless all items are the same as SE `F10N 1: If the same, write 'SAMU'.AS S171T. across <br /> this section. Be sure to check TANK OWNrJtSIffP'I-fPF box. <br /> IV� BOARD OF EQIJAY17AIlON UST STORAGE FlUi AC(-'OUNr NUMBER(MUST BE CoMPj1-QTiD) <br /> Enter your Board of Equalization (130F) USF storage fee account number which is required before your permit application <br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting,the <br /> W006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The 130E will code persons exempt from <br /> paying the storage fee so returns will not be sent. If you do not have an account number with the BO1', or if you have any <br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the-BOE at the following address: <br /> Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. <br /> ST 4 -OMP E-1 I <br /> V. PE`1'1?,OIEUM US7 FINANCIAL RESPONSIRII.ITY (MU, BL C I - 7E <br /> Identify the methods) used by the owner and/or operator in meeting the Federal and State financial responsibility <br /> requirements. USTs owned by any federal or State agency are exempt from this requirement. <br /> VI. LEGAL N(Y11I7l(A`nON AND BH1JNG ADDRI.iSS <br /> Check ONE BOX for the address that will be used for BOTIf I,HGAL AND BILTING WITFICA11ONS. <br /> APPIJCAN'r MUST SIGN AND DAI1inIE FORM AS INDICAIT0. <br /> INSFRUCHON FOR 11.11?WCAL AGENCFFS <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The <br /> facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any <br /> alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. <br /> r1' IS 17TH RESPONSIBIU17Y OF 771H LOCAL . GEWY TIIAT 1NSPF `I1S'I11E FACHIff TO VERH?Y 7W <br /> ACCURACN OF 1111.1 INIURNIN110N. '1711S APPLICATION CANNOT BF PROCESSED IF IT-IH BOE A(X,'OtJNI' <br /> NUMBER IS NOT FILLED IM ITIF I J1'CAL AfiENCY IS RBSPONSIBW FOR*17W COMPLE-nON OF <br /> 'IXICA11, AGE WY USE ONLY' INFORMA410N J`V)X AND FOR FORWARDING ONE FORM "A'AND <br /> ASS OCIAIMI) FORM W(s)TO TO FO ALT ADDRP-Si, <br /> SYA717 OF k,*,MJ(C RN1A <br /> STA T, WATER IWSOURCES COWROL BOARD <br /> C/o smWnnI F-9, <br /> DNIA PRO(,n%SING CT.Nrill'R <br /> P.O. BOX 527 <br /> PARAMOUIVI', CA 90723 <br />
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