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_ w <br /> I ii` QCT Dl)/1/`l)111J /`/lUClil in A TStI ➢!1U ,- <br /> �I TANKS <br /> UNDERGROUND STORAGE TANKS L FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION E3 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CBANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> (Check ane item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION Ple��lo7�(0 <br /> BUSINESS NAME(s.mea..FACR=NA ,uDaA-rofngnaaineas A.) 3 1 FACILITY IDB <br /> SAFEWAY-,FUEL CENTER #1769 (D(29(oH <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT' <br /> FONTANA $] 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS [2 1.GAS STATION Ll 3.FAFJA ❑5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY' ao2 <br /> TOTAL NUMBER OF TANKS Is fwility 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 trustiands�?R operates the UST(This is the contact person for the tank records.) <br /> 2 ao4 ❑ Yes 1H4 No 405 4a6 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> DENNIS JACOBSEN FAMILY HOLDINGS 818-251-9919 <br /> MAILING OR STREET ADDRESS 409 <br /> 23433 H4� AS STREET <br /> CTFY'=- 410 STATE 411 ZIP CODE 412 <br /> WOODLAND HILLS CA 91367 <br /> PROPERTY OWNER TYPE 0 L CORPORATION ❑2.INDMDUAL [14.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> 0 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 /> AAFEWAY <br /> MAILING OR TREET ADDRESS 416 <br /> 5918 STONERIDGE MALL ROAD <br /> CITY 417 1 STATE 418 ZIPCODE 419 <br /> PLEASANTON CA 94588 <br /> TANK OWNER TYPE KI L CORPORATION 0 2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 4N <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [f 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [15.LETTER OF CREDIT [18.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 one box to indicate which address should be used for legal notifications and mailing. ,yy <br /> Legal notifications and mailings will be sent to the tank owner unless box l or 2 is checked. [1Cf 1.FACILITY ❑2. PROPERTY OWNER 3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is hue and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> 925-467-3840 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> NANCY VOVES STORE DESIGNER <br /> STATE UST FACILITY NUMBER(For loco use only) 478 1998 UPGRADE CERTIFICATE NUMBER(For local ase only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />