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Ah • rTNIFIED PROGRAM CONSOLIDATED FORMqW PR#:PR0231446 rC#:FA0000853 � S �o3 UNDERGROUND STORAGE TANKS -FACILI �U� e page site) TYPE OF ACTION ❑ LNEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ 8' D ❑6.TEMPORARY SITE CLOSURE f�J(O7 � - L FACILITY f SITE INFORMATION 1205 E NORTH ST.MANTECA ' BUSINESS NAME(Snnaas FACarry NAME,xDRA-Dchx1Eu51�sAs) 3 FACR.ITY[D# PR m# n� 1 DOCTORS HOSPITAL OF MANTECA FA0000853 PR0231446 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT 401 ❑ I.CORPORATION NORTH ❑ 5.STATECOUNTY AGENCY' BUSINESS ❑ 2.MDIVIDUAL ❑ 6.STATE AGENCY" TYPE ❑ 1.GAS STATION ❑ 7.FARM ❑ 5.COMMERCLU. ❑ 3 PARTNERSHIP 4oE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •Ifowner of UST is a public agency:name of supervisor ofdivisim,section or office,which operates REMAINING E SITE trustlands? the UST(This is Ne contact person for the tank records.) 404 EJYes ® No 405 FRED MARTIN 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4oi PHONE 409 20Q 823-3111 MAILING OR STREET ADDRESS 409 1205 E NORTH ST CITY 410 STATE su ZIP CODE 412 MANTECA I CA 95350 PROPERTY OWNER TYPE ® I CORPORATION ❑ 2.INDIVIDUAL ❑ 4.FOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 111.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 DOCTORS HOSPITAL OF MANTECA 209 823-3111 MAILING OR STREET ADDRESS 416 CITY 1205 E NORTH ST 417 STATE ata 1 ZIP CODE 419 MANTECA CA 95350 TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024696 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑X 99.OTHER ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER an Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE azo PHONE azs NAME OF APPLICANT(print) 436 TITLE OF APPLICANT an STATE UST FACILITY NUMBER(a9rl9u<only) 429 1998 UPGRADE CERTIFICATE NUMBER(Fv low--WY) azs Is 1998 Compliant?Y UPCF(1/99 revised)