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UNIFIED PROGRAM CONSOLIDATED FORM \ �b Q l L) <br /> UNDERGROUND STORAGE TANK O <br /> OPERATING PERMIT APPLICATION- FACILITY IORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT Z 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4041 FACILITY ID <br /> 1 (Agency Use Only) v U ! <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> SAN JOAQUIN GENERAL HOSPITAL <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 500 WEST HOSPITAL ROAD FRENCH CAMP <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> SAN JOAQUIN GENERAL HOSPITAL (209)468-3257 <br /> MAILING ADDRESS 409. <br /> P b . low <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> CA Z� <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> SAN JOAQUIN GENERAL HOSPITAL (209)468-3257 <br /> MAILING ADDRESS 428-3. <br /> 500 WEST HOSPITAL ROAD <br /> CITY STATE ZIP CODE 428-6. <br /> 428 4. 795231 <br /> FREENCH CAMP CA <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAMEPHONE 415. <br /> SAN JOAQUIN GENERAL414.HOSPITAL (209)468-3257 <br /> MAILING ADDRESS 416. <br /> ?• � • ��� /v2o <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> P Gj CA <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT 14 5.COLNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O 2 '4' JC' ro I Z I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: Z 1.FACILITY OWNER ® 4.TANK OPERATOR 423. <br /> Z 3.TANK OWNER ® 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> JESSE ESCOTTO ASSISTANT FACILITY MANAGER <br /> VII.APPLICANT SIGNATURE " <br /> CERTIFICATION: I certify that the infornmtion provided herein is true,accurate,and in full compliance with legal require' <br /> APPL NATURE DATE 424 1 PHONE 425. <br /> 9/9/2009 (209) 367- ' <br /> APPLICANT (print) V 426. APPLICANT TITLE 427 <br /> JOSEP AGLEY CONTRACTOR FOR SJ GEN HOEVITAL <br /> 311 <br />