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Ju-- 27 01 11 : 25. <br /> ... p. 2 <br /> . �•-.... vu.0 a•aau rvVoana an"v" pr ../ <br /> UNDERGROUND STORAGE TANKS - FACU.[TY TANKS <br /> LT"EACTION L NEW SITE PERMIT ❑3.RENEWAL PERMIT S.CNOF INFORMATRW Z <br /> Med oa=;wa^1AJ7 I6oe Pge P�dle) Page�of <br /> D6.AMfiNDEUPERMR ANGE ym5,dmW tl 7YRRMANUOTLYCL <br /> -.•-.--O B.TANRREMOVEO SCD SRL j <br /> 1:16.1tMPORARY SITE CLOSURE <br /> i L FACILITY/SITE a01 <br /> I TE INFORMATION <br /> RIfiINFS$NAMEINAbIB ls.weu sAcn.nYNAn4:u ue.._ <br /> SAFEWAY 0°'•sN"':'s`^'1 i I'ACII.ITY IDB <br /> �--- � ITER I#1769 - <br /> I NEAREST CRASS STREET ...�--^ D 7 (o [� 12 y <br /> Z <br /> vi FACILITY OWN TI'PE <br /> C'd•� C G 4.LOCAL AGENI:Y/DISTRICT* <br /> BU$IbIESg 1.GAS STATION � ' 0 L-qr�. %I I.TIC RATION I <br /> C13.FARM 5. COMMERCIAL ❑5.COUNTY AGENCY* <br /> "I'YPF" ❑2.DISTRIBUTOR Q4,PROCESSOR ❑ 2.INDIVIDUAL <br /> NUMBER OF ❑6.OTHER 1:16,STATE ACFNCY• <br /> TOTAL NI gIdK3 av ❑ 3.PARTNPRSHIP � <br /> REMAINING AT SITE fa stla yon Indian R aIW.of •1 •weQ orU3T Tea ❑7.FEDERAL AGENCY• <br /> trusltRrvk7 P°bd. nancayprr.iyra'dl.ip.r, �J <br /> CK ❑ YeaR No npeulRa ma U3T(lLie is me awrep+emimaw vale waeds.) aeokaW olEee rttiim I <br /> f <br /> j R. PROPERTY OWNER TNI pRMAT10N <br /> PROPERTY OWNER NAMC I <br /> I DENNIS JACO85EN FAMILY HOLDINGS n' _ <br /> D "-• <br /> MAILING ORSTREETADRESS -_.._ 818 251-9919 'a <br /> --y-�" <br /> J"4d�R HATTF'Iln <br /> !. CITY �••S SPRFFT <br /> WOODLAND HILLS Ji0 STATE <br /> LiP C <br /> j FROPERT}'OWNERT I'O91367 413 j <br /> TYPE I,CURRAT'ION 2.lNDIVIDIIAL � ODE <br /> 4.LOCAL AGFfJCY/DfSTRICI' -- <br /> M 3.PARTNFRSI RP L7 5.COUNTY AGENCY ❑b.STATE AGENCY <br /> ❑7.TEDERAL AGENCY +O <br /> _ III.TANK OWNER INFORMATION <br /> TANK OWNER NAME I <br /> 414I PHONE ----�� <br /> 925-467-3000 <br /> I MAILING OR STREET AI7URE5$ 1_... <br /> 5918 STONERIDGE MALL ROAD __ <br /> j cfrY - <br /> eii STATE j <br /> PLEASANTON *u ZIPCODE no <br /> r TANT.OWN_� (- 'R7Ypg ^" I.CORPORATION CA 9�I588 - <br /> Q 2.fNDIVIDIIAL ❑4.LOCAL AGENL'Y 1 DISTRICT' 6.STATE AGENCY <br /> IJ 1 PARTNERSHIP ❑5.COUNTY <br /> ❑7.FEDERAL AGL•NCY <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> j TY TK)HQ 44 6 0� Call(9169 j fquc ons arise - Q1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) Cll 1.SGLF-RJSIJRED ❑4.SURETY BONb ❑7.$TATE FUNU <br /> ❑2.GUARANI'EE ❑5.L=- ,R OF CREDIT(7 S.STATE FUND&CFU LEITER ❑IU.LACAL GOVT MECHANISM <br /> ❑3.INSURANCE ❑6.ExEMPIIoN Q 99.OTHER:_ <br /> • ❑9.STATE Ft1ND&CD is <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbe6 me bot to iedicec w ' admom dmeld be wed Rw legal weEWdumaed meilm(r <br /> Lops Rad6tadaa aaa m4il:gs mrR be raa m dw Ia.di owner antras bea I m2ls rLrd-ed L] I.FACILITY <br /> • 02 PROPERTY OWNER 141TANKDWNEII IU <br /> VII.APPLICANT SIGNATURE <br /> CeaoSgfipa'J-4 maithe-fia- ion poridad Iw.e1e Ktree aidattmvabIk bra ofmy IasaWodge. <br /> �11c,hAS RIi OF APPLIC;rlN7 DATE R4 PFNRVE i35 <br /> cJ VL.�. ?� :''; 805--5491 f1J8. <br /> _.. N A'N'TIIH1n�- z) •1�6 TI LE OF APPLICANT <br /> hY LE5 PROJECT MANAGER <br /> STATE IIST FACILITY NUMBER(r+�.iew,,,,,oy) TN I"R UPCRADE CLRIIFICATE NUMBER(im:dne.,*) ap <br /> UPCF(1/99 revised) 8 FOrmo IY SWRCB Form A <br />