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Auk A=k al�sG 0\ <br /> ?VIED PROGRAM CONSOLIDATED FO ' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY ` <br /> 1C 00 t 3 5003p page per site) Page_of <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) [18.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE DI IZI O j <br /> I. FACILITY/SITE INFORINIATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3• FACILITY 1 <br /> Safeway Store#2600 1987-West 11th Street ID# <br /> o D ,.. 3 0 <br /> NEAREST CROSS STREET aol. IFAC13. <br /> OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* aoz. <br /> NE West 11th Street and Corral Hollow Road ® 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM [15.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ®2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP [17.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 /> II. PROPERTY OWNER INFORMATION <br /> 407• PHONE 408. <br /> PROPERTY ONER NANfE <br /> W <br /> Safeway Inc. 925 467-2078 <br /> 409. <br /> MAILING OR STREET ADDRESS <br /> 5918 Stoneridge Mall Drive <br /> CITY Oto• STATE 411. ZIP CODE atz. <br /> Pleasanton CA 94588-2704 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT LJ 6.STATE AGENCY 4t3. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IIL TANK OWNER INFORMATION' <br /> TANKOWNERNAME a14. PHONE +ts. <br /> (925)467-2078 <br /> SafewayInc. 416. <br /> MAILING OR STREET ADDRESS <br /> 5918 Stoneridge Mall Drive <br /> CITY 417. STATE �418. ZIP CODEats. <br /> Pleasanton CA 4588-2704 <br /> TANK OWNER TYPE ®1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 4 1 0 1 8 1 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 /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. El 1.FACILITY [12. PROPERTY OWNER ®3.TANK OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> DATE 424. PHONE 425. <br /> SIGNATURE OF APPLICANT 4 _ 10.08.01 (707)765-1660 <br /> 'f 426• TITLE OF APPLICANT 427 <br /> NAME OF APPLICANT(print) <br /> RHL Design Group Inc./Ingmar Walter Job Captain <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 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 />