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UNIFIED PROGRAM CONSOLIDATED FORM - <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (Oae form per twilltyl <br /> TYPE OF ACTION 0 I.NF.W PERMIT ® 5.CHANGE OF INFORMATION 0 7.PERMANENT FACILITY CLOSURE Jw' <br /> IC6.ct aa.am valyl 0 3 RENEWALPERMIT 0 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4O1' FACILITY IDN <br /> One (,lgenoy We Only) F I A — 0 0 0 — 3 7 6 1 / <br /> BUSINESS NAME(s>.ne n FACI.IrY NAME m Dun-Duma Baia—AL1 <br /> St.Josephs Medical Center <br /> BUSINESS SITE ADDRESS 101 CITY 1w. <br /> 1800 North California Street Stockton <br /> FACILITY TYPE ❑ I.MOTOR VEIIICLE PURLING ❑ 2.FUEL DISTRI13UTION wl' Is the facility located un Indian R.vw,un w +o]. <br /> 3.FARM El 4.PROCESSOR 0 6.OTHER -Inst lands? 0 Yes M No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE +ee. <br /> St Josephs Medical Center <br /> 209 9432000 <br /> MAILING ADDRESS +os. <br /> 1800 North California Street <br /> CITY 418 1 STATE 4n ZIP CODE +11 <br /> Stockton California 95204 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> St Josephs Medical Center <br /> 843-2000 <br /> MAILING ADDRESS +2s.1 <br /> 1800 North California Street <br /> CITY +�+ STATE 428-5 ZIP CODE 4� <br /> Stockton California 95204 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME aa. PHONE ns. <br /> St Josephs Medical center 209 943-2000 <br /> MAILING ADDRESS 416. <br /> 1800 North California Street <br /> CITY +1r. STATE ate. ZIPCODE +ts. <br /> Stockton California 95204 <br /> OWNER TYPE: 0 4.LOCAL AGENCY/DISTRICT 0 5.COUNTY AGENCY ❑ 6.STATE AGENCY 430, <br /> 0 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 2 1 4 1 5 1 0 1 0 1 Call the State Board of Egmlintion,Fuel Tars Division,ifthere are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> [Mue permit and tend legal mtifimnons and mailings Io: ❑ I FACILITY OWNER 0 4.TANK OPERATOR +n - <br /> ❑ 3.TANK OWNER ® 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) wa' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 cerd t the information provided herein is true,accurate,and in full cons lumen with lettid reguirmains. <br /> APPLICANT SIGNATURE DATE +y+ PHONE +3 <br /> October 7,2006 209 461-6818 <br /> APPLICANT NAME(print) +=6 APPLICANT TITLE 427 <br /> John C-Stagg AssistantChief Engineer ��. <br /> UPCF UST-A Rev.(1212087) <br />