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NIFIED PROGRAM CONSOLIDATED FORK PR#:PRO232494 <br /> FAC#:FA0002602 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) � 71M <br /> ❑4.AMENDED PERMIT111k ) ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 7373 WEST LN STOCKTON <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# <br /> KAISER PERMANENTE FA0002602 PR0232494 1 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE El4.LOCAL AGENCY/DISTRICT* <br /> WEST 401 M 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS ❑ I GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* <br /> TYPE 2.DISTRIBUTOR 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP * 402 <br /> ❑ ❑ ❑ 7.FEDERAL AGENCY <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes ® No 405 BILL BERGSTROM 406 <br /> I1.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> KAISER PERMANENTE 209 476-2000 <br /> MAILING OR STREET ADDRESS 409 <br /> 1305 TOMMY DON <br /> CITY 411 STATE 411 ZIP CODE 412 <br /> STOCKTON CA 95210 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> KAISER PERMANENTE 209 476-2000 <br /> MAILING OR STREET ADDRESS 416 <br /> 7373 WEST LANE <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> STOCKTON CA 95210 <br /> TANK OWNER TYPE ❑9 I.CORPORATION ❑ 2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-033865 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER N1 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. M 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 1241 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For Imal use only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />