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UaEWD PROGRAM CONSOLIDA D F I <br /> OCT 2 6 2007_ <br /> TAIfK"�" <br /> UNDERGROUND STORAGE TA - Fv4C t TY Iplg� <br /> i (one page per site) <br /> ......__..____.__ _ <br /> TYPE on ACTION Page _ of <br /> r 1.NEW SITE PERMIT X 3.RENEWAL PERMIT r5HANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one Rem only) .C <br /> r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> 26 qq -7 <br /> V 2 �.,LN�ITr LIZ J l/ I.FACILITY I SITE INFORMATION C-55 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> Safeway, Fuel Station 1769-10 I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE <br /> r 4. LOCAL AGENCY/DISTRICT' <br /> X 1. CORPORATION r 5. COUNTY AGENCY' <br /> BUSINESS TYPE X 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r r 6. STATE AGENCY' <br /> 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP <br /> r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9f owner of UST Is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 3 X r No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Safeway Inc 925/467-3000 <br /> MAILING OR STREET ADDRESS 409 <br /> 5918 Stoneridge Mall Rd <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Pleasanton CA 94588-3229 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> X 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r T FEDERALAGENCV <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Safeway Inc <br /> MAILING OR STREET ADDRESS 416 <br /> 5918 Stoneridge Mall Rd <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Pleasanton CA 94588-3229 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> X 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCV r 7. FEDERALAGENCV <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODS) X 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r B. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> X 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check on eboxtoindiptewhichaddress should be used for legal notifications and nailing. X 2. PROPERTY OWNER 423 <br /> Le al notifications and mailin swill be sent to the tank owner unless box 1 or 2 is checketl. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the info r ion provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> Butch Hobson 426 Safety and Environmental Affairs Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1199 revised) 5 Formerly SWRCB Form A <br />