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+ IFIED PROGRAM CONSOLIDATED FOR I I-103PR#:PR0231446 FAC#:FA0000853 UNDERGROUND STORAGE TANKS -F Imo" .(x103 (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF MFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT gsrcl[y drat#loo.. ❑ S.TANK REMOVED e ❑6.TEMPORARY SITE CLOSURE � 1.FACILITY/SITE INFORMATION 1205 E NORTH ST.MANTECA BUSINESS NAME(Srmcw FACILITY NAME or DBA-fbieg Business As) 3 FACILITY ID# PR ID DOCTORS HOSPITAL OF MANTECA FA0000853 PRO 231446 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT' OOt El I.CORPORATION NORTH ❑ S.COUNTY AGENCY' BUSINESS ® 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL [-1 6.STATE AGENCY' TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP402 E] 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'Ifowner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the rank records.) <a4 ❑ Yes ® No 405 FRED MARTIN 406 U.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE sos DOCTORS HOSPITAL OF MANTECA 209 823-3111 MAILING OR STREET ADDRESS 409 1205 E NORTH ST CITY 410 STATE qll ZIP CODE 412 MANTECA CA 1 95350 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 111.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 DOCTORS HOSPITAL OF MANTECA 209 823-3111 MAILING OR STREET ADDRESS 416 1205 E NORTH ST CITY 417 STATEqts ZIP CODE qty MANTECA CA 95350 TANK OWNER TYPE ❑X 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024696 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X❑99.OTHER ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD a2 VL LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. M I.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the mnk owner unless box I m 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best army knowledge. SIGNATURE OF APPLICANT DATE q2q PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(F.,ioc4t ae mdy) 428 1998 UPGRADE CERTIFICATE NUMBER fForl«,Imeonly) 429 Is 1998 Compliant?Y UPCF(1/99 revised)