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'NIFIED PROGRAM CONSOLIDATED FORAPR#:PRO517565 FAC#:FA0013M UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use Doty ❑ 8.T K REMOVED ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 1987 W 11TH ST.TRACY BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# SAFEWAY#2600 FA0013503 PR0517565 NEAREST CROSS STREET FACILITY OWNER TYPE ELEVENTH 401 ® 1.CORPORATION ❑4.LOCAL AGENCY/DISTRICT' 5.COUNTY AGENCY' BUSINESS E] 1. 2.INDIVIDUAL ❑ TYPE 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑6.STATE AGENCY' ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner of UST is a public ency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact son for the tank records.) aoa ElYes ® No 403 EWAY C 406 II.PROPERTY ER IN RNIION PROPERTY OWNER NAME 407 PHONE 408 SAFEWAY INC JX602 588-6363 MAILING OR STREET ADDRESS 409 PO BOX 29096 CITY 0 S411 ZIP CODE 412 ZAZ PHOENIX 85038-9096 PROPERTY OWNER TYPE ❑ L CORPORATIONAL X4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY PAR S 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 II. NK WN IN TANK OWNER NAME 414 PHONE 415 SAFEWAY INC (602) 588-6363 MAILING OR STREET ADDRESS 416 PO BOX 29096 CITY 417STATE 47, [ZIP CODE 419 PHOENIX z AZ 85038-9096 TANK OWNER TYPE ❑ 1.CORPORARN ❑ 2. I UAL 1:14.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 El3. RSHIP ❑ 5.COUNTY AGENCY El 7.FEDERAL AGENCY TANK PERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE TODD REAL ESTATE MGR IV.BOARD OF EQU IZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-040801 1 Call(916)322-9669 if questions arise 421 V.PET LEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED4.SURETY BOND El7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 5.LETTER OF CREDIT E] 8.STATE FUND&CFO LETTER ®99.OTHER ❑3.INSURANCE /E3 6.EXEMPTION El9.STATE FUND&CD 422 VI. EGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for le notifications and mailing. 1.FACILITY M 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owne less box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided her in is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For ocal ue only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)