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I.,�s�. •s 9k��r�Rec..--.®,�,rr�'W�sr"'-cy`v -n Pry +e�w+r F�'�v �• ,-., qvf, _F"'".,..a� �y.,a"�,•gv.s�.,,_.... J.s.�'-. f-^r+ air v j 1 <br /> rj <br /> y�0'K�•T hf <br /> STA OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> WP: •;JA <br /> FORM`A': '. <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® = <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE llFOR <br /> " <br /> I CD <br /> MARK ONLY 0 ) NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL TE N <br />{ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O / <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 40 <br />`r <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> STOCKTON KAISER MEDICAL CENTER McCARTHY, P.O. BOX 690635, STOCKTON, 95269 <br /> ADDRESS 4� GR6£S�.TRELT ,}�Boxtoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 7373 WEST LANE11�C11VVWW1IVV Qt �I CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> KATHLEEN ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> STOCKTON CA 1 95210 1 (209) 956-3201 <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR F-1 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM X 5 OTHER RESERVATION or #of TANK's <br /> ❑ ❑ TRUST LANDS ❑ NONE AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> BILL BERGSTROM (209) 476-3112 JOHN FARRELL (209) 476-3300 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> KAISER PERMANENTE <br /> MAILING or STREET ADDRESSox to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> 1950 FRANKLIN ROAD CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> OAKLAND CA 94612 (415) 982234 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> KAISER PERMANENTE <br /> k MAILING or STREET ADDRESS L4Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> d 1950 FRANKLIN STREET { CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> OAKLAND CA 94612 (415) 987-2234 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. X❑ if. ❑ Ill. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> ANT' E SIGNATURE) t DATE <br /> L AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# I #of TANKS at SITE <br /> m o 9 © � o / <br /> CURRENT L GENCY FACILITY ID# APPROVED BY E PHONE#WITH AREA CODE <br /> K Se- 9 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F <br /> YES NO ❑ 1101TVdV"-- <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B . <br /> J ao <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THISCHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> w\ c) , 3 —CIO <br /> DATA PROCESSING COPY <br />