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RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM L � . <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACIL T ON <br /> (One form per facility) PERMIT/SERVICES <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY I 404, FACILITY ID# 0 _ _ f �s 1 <br /> (Agency Use Only) G � <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Ka iser Permanente Medical Offices <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 7373 West Lane Stockton <br /> 403. 405. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Ka iser Permanente 209 476-5000 <br /> 409. <br /> MAILING ADDRESS <br /> 7373 West Lane <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Stockton Ca 95210 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1.j PHONE 428-2. <br /> 4 <br /> "'�tDarryl Gardner (209)476-3077 <br /> 428-3. <br /> MAILING ADDRESS <br /> 7373 West Lane <br /> CITY 428-4. STATE 428-5. ZIP CODE 428-6. <br /> Stockton Ca 95210 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> Ka iser Permanente (209)476-5000 <br /> 416. <br /> MAILING ADDRESS <br /> 7373 West Lane <br /> CITY 417. 1 STATE 418. 1 ZIP CODE 419, <br /> Stockton Ca 95210 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 120. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 3 3 $ 6 1 5 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> \ I. APPLICANT SIGNATURE •�`` "� <br /> CERTIFICATION: I c if hat i form on rovided herein is true,accurate,and in full compliance wit le a1 requirements. <br /> APPLICANT SIGNATOR DATE aza. p ONt 425. <br /> A7/21/2011 Q 476-3077 <br /> APPLICANT NAME(print) 426. 1 APPLICANT TITLE 427 <br /> Darryl Gardner <br /> Chief Engineer ,,.�.:.. <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />