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UNIFIED PROGRAM CONSOLIDATED FORM p <br /> UNDERGROUND STORAGE TANK L ,D <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ <br /> 3 (Agency Use Only) -F-7- I I I I � -6 13� <br /> BUSINESS NAME(Same m FACILITYNAME or DBA-Doing Busin s As) 3. <br /> Safeway Fuel Station 2600-10 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1987 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 77PHONE4o5. <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 I 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 NAMEPHONE 415. <br /> Safeway7(925) <br /> Inc. 467-3000 <br /> MAILING ADDRESS 416. <br /> P.O.Box 9070/6000 Stoneridge Mall Road <br /> CITY 417. 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: ® 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 <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal re uirements. <br /> APPLICANT S G ATURE DATE 424• PHONE 425. <br /> 9/3/2009 925 469-7164 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4n <br /> Butch Hobson Safety and Environmental Affairs Manager <br /> UPCF UST-A Rev.(12/2007) <br />