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U' -TED PROGRAM CONSOLIDATED FORT <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> 3 5()(C page per site) Page of <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 101 12-1 0 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> SafewayStore#2600 1987-West 11th Street ID# [� D » 3 D � � I � � � ' <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> NE West 11th Street and Corral Hollow Road ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ®2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 2 ❑Yes ®No <br /> . ... ... _..._ <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408, <br /> Safeway Inc. (925)467-2078 <br /> MAILING OR STRI:i T ADDRESS 409. <br /> 5918 Stoneridge Mall Drive <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Pleasanton CA 94588-2704 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> __ ... _ .... ... _ .............. .._ <br /> " III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PIIONE 415. <br /> Safeway Inc. (925)467-2078 <br /> MAILING OR STREET ADDRESS 416. <br /> 5918 Stoneridge Mall Drive <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Pleasanton CA 94588-2704 <br /> TANK OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ........................................................................ <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> ......... ...._... ................ <br /> V $OARD OF,EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- 1 0 1 4 1 0 8 0 1 Call (916)322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> .... <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423• <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. PHONE 425• <br /> 10.08.01 (707)765-1660 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427• <br /> RHL Design Group Inc./Ingmar Walter Job Captain <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />