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Rio RN Pq I -INIFIED PROGRAM CONSOLIDATED FOA' Li� PR #:PR0231036 FAC#:FA0003761 400oS MOO UNDERGROUND STORAGE TANKS -FACILINXR 0 7 2003 one per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION PE�i ... LOSED SITE (Check one item onty) ❑4,AMENDED PERMIT 81./Ti7 ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1800 N CALIFORNIA ST.STOCKTON BUSINESS NAME(sae as FACILITY NAME or DBA-rains Bminras As) 3 FACHM ID# I PR ID# ST JOSEPHS HOSPITAL FA0003761 PR0231036 NEAREST CROSS STREET FACILITY OWNER TYPE 401 C:]�.,/ 4.LOCAL AGENCY/DISTRICT- CALIFORNIA 1.CORPORATION [15.COUNTY AGENCY' BUSINESS ❑ L GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL TYPE � ❑6.STATE AGENCY• ❑ 2.DISTRIBUTOR ❑4.PROCESSOR [y o.OTHER 4m ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* r1()2 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or REMAINING AT SITE Irusdands? 'Ifowner ofUST is a public agency:name of supervisor ofdivision,section or office which operates the UST(This is the contact person for the tank records.) <O4 ❑ Yes ® No 405 ST JOSEPHS HOSPITAL II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409 (209)825-3516 MAILING OR STREET ADDRESS 4a9 1800 N CALIFORNIA ST CITY 410 STATE 411 ZIP CODE - 412 STOCKTON I CA 1 95204 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY El 3.PARTNERSHIP [:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 111.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 413 ST JOSEPHS MEDICAL CENTER CORP 209 825-3516 MAILING OR STREET ADDRESS 416 1800 N CALIFORNIA ST CITY 417 1 STATE 419 ZIP CODE 019 STOCKTON CA 95204 TANK OWNER TYPE ® I.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- 44-024500 Call(916)322-9669 if questions arise 411 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) EM 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ®99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® I.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Lcgal notifications and maifing will be sent to the lank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE C 'ficadon-I certify thin the information provided herein is we and accurate to the best ofmy knowledge. SI TURE OF APPLICAN DATE 424 PHONE 425 3- v3 aoa- �lb�-Saaa NAM APP ANT P bz4 TITLE OF APPLICANT bn STA ST FACILITY NUMBERIym foul ma 429 1998 UPGRADE CERTIFICA NUMBER(For mol use omy) 429 Is 1998 Compliant?Y UPCF(1/99 revised)