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Jul 20 01 10: 10a p. 2 <br /> . ,..�.... ..o.s4•u.sa cnwcnt t-n ATvn at <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> lom page PQ sial Page t ofA- <br /> TYPE OF ACTION 9R 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑SCTUNGE OF INFORMATION ❑ 7PERMANENTLYCLOSEDSITL <br /> (Che&om i.en ady) ❑4.AMENDED PERMIT V-dfy -F k cA esc tasty ❑ R.TANK REMOVED <br /> E3 b.TEMPORARY SITE CLOSURE 4m <br /> r <br /> � i. FACILITY/SITE INFORMATION <br /> t BUSINESS NAM£R....a.PAcnmWn .o - A) - FACILITY II%. <br /> SAFEWAY.FUEL CENTER #1769 ' <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT' <br /> 2ecob Grloil Y GL-L� NbL.UA. E3 I.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 0 5. COMMERCIAL ❑ 2.INDMDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBI7TOR [14.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 4m <br /> TOTAL NUMBER OF TANKS Is facility m Indian Rcrt.vatian of 'Ir...fUST a apablicgc,,y:amteafsspavisor ordi.•L.im scetim w wbca whits <br /> REMAINMGATSITE ouvlanw aPcnles the UST(This is Ibe mnlsY person few the lsDtl nxmds.) <br /> 494 ❑ Yes It No 405 <br /> 44a <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAME m7 PHONE q <br /> DE[QNIS JACOBSEN FAMILY HOLDINGS 818-251- 1919 <br /> IMAILING OR STREET ADDRESS <br /> 23433 HATTERAS STREET <br /> CITY - - ltd STATE Ott <br /> Z <br /> WOLA@ID HILLS CA , 91367 4i3 <br /> OD <br /> PROPERTY OWNER TYPE EILCORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY --1 <br /> 1A 3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY uy <br /> I Iii.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 I PHONE925-467-3000 ns <br /> I <br /> I AAFMAV, INC!- <br /> MAILINGOKSTREET ADDRESS 4166 <br /> 5918 STONERIDGE MALL ROAD <br /> I <br /> CITY 417 STATE 4t, ZIP CODE 4m <br /> PLEASAN ON CA 94588 <br /> 1 TANK OWNER TYPE I-CORPORATION 2ANDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 6.STATEAGENCY 4ea <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call 916 322-9669 if questions arise m <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) LE 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OFCREDIT ❑S.STATE Fl1ND&CFO LETTER ❑ 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPITON ❑9.STATE FUND&CD 4II <br /> L VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbek one boy to md,We which ebdr=should be wed fm IcXd v;Wfi��m adwdmg <br /> Lapp O1.FACILITY ❑2. PROPERTY OWNER 93.TANK OWNER nJ � <br /> VII.APPLICANT SIGNATURE <br /> Ceni6mioa)1=ify do the mf".provided Nemo i$Mand-=to the hatofmy koowled¢ <br /> s.S10NA3'{7RE Of AFP�IC,(124T DA"I'E .. ss4 <br /> FF PHONF. a. i <br /> r...^ ^'yJ,...,� ':�,Wa• {. -- i 805-549-8658 <br /> 1prmq '°s TrrLE O APPLICANT 4n <br /> JEUREY LEE PROTECT MANAGER f <br /> STATE UST FACII.f1Y NIfMB£R Ra.locr uamy) �y 1998 UPGRADE CERTIFICATE NUMBER(Fwbot..ep 4a9 <br /> i <br /> UPCF(1/99 revised) 8 Formerly SWRCR Form A <br />