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IFIED PROGRAM CONSOLIDATED FOMI 1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> an <br /> TION I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSUREJYPE <br /> only) ® 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF LISTS AT FACILITY 404' FACILITY ID# 1 <br /> 3 (Agency Use Only) T-17 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> Safeway Fuel Station 2600-10 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 1804 West 11th Street Trac <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> Safeway Inc. (925)467-3000 <br /> MAILING ADDRESS 409. <br /> P.O. Box 9070/6000 Stoneridge Mall Road <br /> CITY 410, STATE 411. ZIP CODE 412, <br /> Pleasanton Ca 94588-3229 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428.2 <br /> Safeway Inc. (925)467-3000 <br /> MAILING ADDRESS 428-3 <br /> P.O. Box 9070/6000 Stoneridge Mall Road <br /> CITY 4284 7 STATE 428-5 ZIP CODE 428-6 <br /> leasanton Ca 94588-3229 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 41s <br /> Safeway Inc. (925)467-3000 <br /> MAILING ADDRESS 416 <br /> P.O. Box 9070/6000 Stoneridge Mall Road <br /> CITY 41 STATE 418, ZIP CODE 419 <br /> Pleasanton Ca 94588-3229 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44 Call the State Board of Equalization.Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 23 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> 8/19/2009 (925)469-7164 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> 'cutch Hobson Safety and Environmental Affairs Manager <br /> UPCF UST-A Rev.(12/2007) <br />