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AN& j a e f,� RECENED <br /> D PROGRAM CONSOLIDATED FEB 11 209 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFO �'IVIRONMEN�T HEAL <br /> er Al <br /> 0/10y "R >��S <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ® 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACII.ITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 1 FACILITY ID it I. <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(same as FAC 1T Y NAME or DBA-Doing Bosmess As) f=f C�� w / �-. ^ 3. <br /> Kaiser Permanente Medical Offices G <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 7373 West Lane Stockton <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 43" Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 08. <br /> Kaiser Permanente (209)476-5000 <br /> MAILING ADDRESS 409. <br /> 7373 West Lane <br /> CITY 410. 1 STATE 411- ZIP CODE 412. <br /> Stockton Ca 95210 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4281 1. PHONE 428-2 <br /> Thomas Lee Hin ston II (707)987-4770 <br /> MAILING ADDRESS 428-3 <br /> 18758 femwood Rd. <br /> CITY 4284 STATE 428-5 1 ZIP CODE 428-6 <br /> Hidden Valley Lake I Ca. 95467 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Kaiser Permanente (209)476-5000 <br /> MAIIUNG ADDRESS 416. <br /> 7373 West Lane <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton J Ca 95210 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8_NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 13 18 161 5 1 Call the State Board of Equalization,Fuel Tax Division, 421. <br /> if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue peamit and send legal notifications and mailings to: ® L FACILITY OWNER ❑ 4_TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4W <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th ation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 425. <br /> 2/9/2009 (209)476-3413 <br /> APPLICANT NAME(print) 1 426. APPLICANT TITLE 427 <br /> Ed Rocha Chief Engineer <br /> UPCF UST.A Rov.(12/2007) <br />