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IFIED PROGRAM CONSOLIDATED FORN711!0I n' if PR#:PR0231736 <br /> {w V FAC#:FA0002562 <br /> UNDERGROUND STORAGE TANKS -FACILITY fir, �y��oLA <br /> t# <br /> (one page per site) ) I <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE 1. <br /> (Check one item only) E] 4.AMENDED PERMIT ❑ 8.TANK REMOVED r <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 1420 N TRACY BLVD,TRACY <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# <br /> SUTTER TRACY COMMUNITY HOSP FA0002562 PR0231736 l <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> TRACY aol ❑ 4.LOCAL AGENCY/DISTRICT' <br /> ❑ 1.CORPORATION <br /> ❑ S.COUNTY AGENCY' <br /> BUSINESS ❑ 1.GAS STATION 3.FARM ❑ 2.INDIVIDUAL <br /> TYPE ❑ ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY' <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 <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 N Yes ❑X No 405 SUTTER TRACY COMMUNITY 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 209 835-1500 <br /> MAILING OR STREET ADDRESS <br /> 409 <br /> 1420 N TRACY BLVD <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> TRACY CA 95376 <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 /> TRACY COMMUNITY MEMORIAL HOSP 209 835-1500 <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> 1420 N TRACY BLVD <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> TRACY CA 195376 <br /> TANK OWNER TYPE ❑9 1.CORPORATION N 2.INDMDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP N 5.COUNTY AGENCY N 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND N 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT El 8.STATE FUND&CFO LETTER ❑X 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. ® 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 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local ao only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />