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Jul 20 01 09: 55a P• 2 <br /> `.a <br /> • na•r u'q VwV`s!!Y /`f1NCflr rP lTSP Vf <br /> JfTANVSSUNDERGROUND STORAGE TANKS- FACILITYIoRpwwsfti pw <br /> 7YPEOFACTION 11 LEW S[TE PERMIT 3-RENEIVALPE[MR 050IANGEOFINPORMAMM D 7lERMANENTLYL7.OSw S;m <br /> iCYat au imm mly) ❑lAM(7YDFD PERMIT wc6y-uw bd sm ody —_D LTANKREMOYEp <br /> D 6:1 LAIWA ARY SITE CLOSURE o <br /> 1. FACILITY I SPIE INFORMATION <br /> 1 <br /> BUSINESS NAME ps...rwR,l}Y MAMespy_DUmq u " I FAC1Lf1Yl1Y <br /> SAFEWAY.-FIM CENTER #1759 ' <br /> NEAREST CROSS STREET 4N FACILITY OWNER TYPE 4.LOCAL AGENCYjgSTRiCC <br /> Zeal i G(}7F TS�Y C-LA vs ${ �l. 13 L CORPORATION 0 5.COUNTY AGENCY+ <br /> BUSINESS I.GAS STATpN ❑3.FARM. S.COMMERCIAL ❑ 2.INWYIDUAL []6.STATE AGENCY- <br /> TYPE 13 7,IMSTRIBUTOR 0 4.PROCESSOR:O 6.OTHER 4n ❑ 3.PARTNERSHIP ❑T.FEDERAL AGENCY- <br /> ; <br /> GENCY- <br /> TOTAL NUMBER OF TANKS [s icibiy on icEmR�vsliso 4r `Ifowon ofUST"ssp6Rcagm„y,�el apwmro[ai�isiy xma w d .whi3 <br /> REMAINMG AT SITE tmwbms? apemis lk UST plum d.osmapmoe Nrtk mamde) <br /> 4N ❑ Ya)U No 46 <br /> a <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME +no <br /> DENNIS JACOBSEN FAMILY HOLDINGS PHONE <br /> 8£251-9919 <br /> MAILING OR STREET ADDRESS <br /> STATE +1' 7IPCUM +u <br /> pWOODLAND BILLS me CA 91367 <br /> I PR4RERTY OWNER TYPE D 1.CORPORATION 2IND(YIDUAI. 0 4.LOCAL AGENCYlgSTRlC! 0 b.STATE A0L74CY <br /> i <br /> f 0 3.PARTNERSIBP ❑5.COIATI'Y AGENCY ❑7.FEDERAL AGENCY .0 t <br /> f RI.TANK OWNER INFORMATION i <br /> i <br /> TANKOWNER NAME Q4 rHONE <br /> ns { <br /> T _SSFFWAY- <br /> TW-- 925-467-3000 <br /> MAILING OR STREET ADDRESS <br /> 5918 STONERIDGE MALL ROAD <br /> 1 <br /> CITY <br /> 41, 1 STATE :,. nrcor <br /> PLEASANTON CA 94588 <br /> iTANKOWNERTYPE KI I.CORPORATION IINDIVIDITAL U 4.LOCAL AGENCY/DISTRICT CSTATEAGBICY ao ' <br /> _ 0 3,PARTNERSHIP ❑5.COUNTY AGENCY 07..FFSIERAI.AaENcr <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TX)HQ 44- 0 1 1 1 Call 916 =-9669 if Restions_mise_ _ m <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICRTE b�J'FIOD(sl l•J I.SF].F-IAIS(ALED [l 4.SIA4'fY BOND 1:17 STATE FIND D 10_LOCAL GOVT ME(,`HA MM � <br /> 0 2 GUARANTEE 0 5.LETTER OFCRFDIT [IS.STATE FUND&CEO LETTER ❑ 99.0'THER_ <br /> I ❑3.INSURANCE ❑b.EXEMPTION [19-STATE RIND&CD m <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Werk eim buc ro is4iab s+udaVs�mdeldisusd Rf Mpl s4URr�f�d vfq .y <br /> Lend souSanmssdsmimp+riR le aatb3e�t4mslmbsala3'm lM3ed D [.FAOiITY ❑2 flRB6RTY Ot4NE[ I'33,TANKOWNFB Q; <br /> I VIL APPLICANT SIGNATURE <br /> f..:e.�...jl xmly LLS W[iu60mp pwl✓a4601RisIRRr4s�leM M WIi�PRw.bV(f ' <br /> GNA3'{3RE OF AP'I�LI ANT DATE rmnNE 4iT <br /> 805-549-6658 <br /> IPPA) _ 4s T17'LE APPLCANT sp <br /> ,1PW8EY LEE ' PROJECT MANAGER <br /> STATE ISTFACIIITYNUMBIER44 .�y7 m 1991 UPORAD(i CERTIFICATE k7l Wms�..wTI <br /> UPCF(1199 revised) $ Fnlm eAY SWRCII Form A <br />