COMPLIANCE INFO_1989-2005 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FOR* PR#:PR0232397 FAC#:FA0003978 UNDERGROUND STORAGE TANKS -FACILITY or ��r r'h A- I (one page per site) V TYPE OF ACTICn 4 ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1777 W YOSEMITE AVE.MANTECA BUSINESS NAME(same as FACBdrY NAME or DBA-Doing Business As) g FACILITY IDq PR ID# ST DOMINIC'S HOSPITAL/MANTECA FA0003978 PR0232397 1 T1 I NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- YOSEMITE 401 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑E]2. 3PARTNERSHIP 402 2.DISTRIBUTOR 4.PROCESSOR �6.OTHER 403 ❑ 7.FEDERAL AGENCY- TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST('this is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNE&NAME _ / / 407 PHONE 408 209 825-3516 MAILING OR STREET AD S •l rY� � �< aov CITY 1 410 STATE au ZIP CODE `//�f atz PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE 415 ST JOSEPHS MEDICAL CENTER CORP 209 825-3516 MAILING OR STREET ADDRESS 416 1805 N CALIFORNIA ST#407 CITY 417 STATE 4t8 ZIP CODE 419 STOCKTON CA 95204 TANK OWNER TYPE 1,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- 44-025023 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER Fx1 99.OTHER ❑3.INSURANCE 1:16.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. M 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is tnie and accurate to the best ofmy knowledge. SIGNATURE OF AP AN DATE 424 PHONE / 425 NAM F APPLICANT(printj 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only) 428 1998 RADE CERTIFICATE NUMBER(For focal use only) 42v Is 1998 Compliant?Y UPCF(1/99 revised)