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rrnr\�.n oonno•ae nnwlcna mArcn cnoa� <br /> Owftj'� <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY x110.; <br /> (one page per site) Page I Of <br /> TYPE OF ACTION I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 4co <br /> L FACILITY/SITE INFORMATION Z Q <br /> BUSINESS NAME(Same,as FACILOY NAME or DBA-Doing aminew Aa) 3 FACILITY IDM // <br /> SAFEWAY_FUEL CENTER #1769 c) % b <br /> NEAREST CROSS STREET or FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT4 <br /> FONPANA 11 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS CR 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 4¢a ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 4oz <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or "If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING.AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes IHS No 405 nob <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> DENNIS JACOBSEN FAMILY HOLDINGS 818-251-9919 <br /> MAILING OR STREET ADDRESS 4w <br /> 23433 HATTERAS EE <br /> CITY '- 410 1 STATE 411 1 ZIP CODE 412 <br /> WOODLAND HILLS CA 91367 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY <br /> 129 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 925-467-3000 <br /> MAILING OR STREET ADDRESS 416 <br /> 5918 STONERIDGE MALL ROAD <br /> CITY 417 1 STATE .419 ZIPCODE 419 <br /> PLEASAN ON CA 94588 <br /> TANKOWNERTYPE El I.CORPORATION 0 2.INDIVIDUAL ❑4.LOCAL.AGENCY/DISTRICT ❑6.STATEAGENCY 4m <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 8 1 0 1 1 1 Call 916 922-9669 if questions arise 9L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [2f 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check me box to indicate which address should be used for legal notificatims and mailing. ,y <br /> Legal notificimoas and mailings will be sent to the tank owner mless box I or 2 is checked [1I.FACILITY ❑2.PROPERTY OWNER 1_}3.TANK OWNER 425 <br /> VII. APPLICANT SIGNATURE <br /> Cenificatim certify that the udi an.provided hemi.is"end acatrate to the best ofmy knowledge. <br /> IGN F I DATE 424 PHONE 4zs <br /> CAN 805-549-8658 <br /> (print) 4z6 TITLE O APPLICANT 4Il <br /> Y LEE PROJECT MANAGER <br /> STATE UST FACILITY NUMBER(For tow uee Dory) 4U 1998 UPGRADE CERTIFICATE NUMBER(For local use may) 424 <br /> UPCF(1/99 revised) 8 �.at( Formerly SWRCB Form A <br />