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Akf Am <br /> FIED PROGRAM CONSOLIDATED FOW. <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION E: -FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURL 40u <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF U FACILITY404. FACILITY ID# <br /> 3 (Agency Use Only) <br /> B ESS N E(Same as FACILITY N or DBA-Doi Business As) 3 <br /> afewa Fel Station 2600-10 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1804 West 11th Street Trac <br /> ACILITY TYPE ® 1.MOTO EHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation o14'0'.3. ❑ 4.PROCESSOR [16.OTHER Trust lands? [3Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE <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. 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 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Pleasanton Ca 94588-3229 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415 <br /> Safeway Inc. (925) 467-3000 <br /> MAILING ADDRESS 416 <br /> P.O.Box 9070/6000 Stoneridge Mall Road <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> Pleasanton Ca 94588-3229 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <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: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE .f <br /> CERTIF ATION: I certify that the information provided herein is true,accurate,and in full com liance with le al re uireme s� <br /> APPLIC SIGNATURE DATE 424. PHONE425. <br /> 8/19/2009 (925) 469-7164 = <br /> APPLICANT NAME(print) 426. APPLICANT TITLE % 427 <br /> Butch Hobson Safety and Environmental Affairs Manager <br /> UPCF UST-A Rev.(12/2007) <br />