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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> E: UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page,of <br /> TYPB OF ACTION 19 L NEW PER1z1T ❑3.RENEWAL PERMIT ❑5.CHANGE OF MORMATION ❑7.PERMANENTLY CLOSED SITE <br /> 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> .-.ry.... ixe r ,� ..d'4b't6if1•+• �� '.',W.X•. ...*4 ..•. <br /> ....n.....wp.• .,.'FS>ert t 3i. i 4 ,.,r.. ... `i;�•- r� l t .'7Y �.��^ <br /> a <br /> °j',:s''r.r ''>pa'•'as r! +r^•�,�•`&'� x c. bh ,r, <s' �,e : �'.a., r.'•�''•c r y-•'"'x. z•z +�t >.':' <br /> z d ,1Y'"v.y .,.r. :. -^-�w .:; .&s ...:.....y',: >l •n r• -~,' ..: d>.x..:,. .:.,,ro„i :•x r s' <br /> BUSINESS NAME(Sawa FACRITY NAMEor DBA-Ddttl3ainexAS) 9. FACILITY � <br /> Safeway Store#2600 1987-West 11th Street ID# <br /> NEARBST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 4a2. <br /> NE West 11th Street and Corral Hollow Road ®1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS MI.GAS STATION 3.FARM 05,CCMMERClAL 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY" <br /> TYPE ®2•DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY• <br /> Is fact7ity on Indian Reservation 405. 'If owner of UST is a public agency:nanM of wpetviaor of division,section or 406 <br /> TOTAL NUMBER OF TANKS <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contactperson for the tank records.) <br /> 3 E]Yes ®N -Emily <br /> Da>gn w5 i u 7 <br /> No Safew E JoAnn eau <br /> n..... <br /> 3srse 3 vv;�� x )= A ""f.,.a.x-r_^ -•c»... �-<v sa. ..:.. ........x �:.. ..w.:. <br /> PROPERTY OWNER NAME 407• PHONE 408, <br /> Safeway Inc, 925 467-2075 <br /> 409 <br /> MAILING OR STREET ADDRESS ' <br /> 5918 Stoneri a Mall Drive <br /> 410. STATE 411. ZIP CODE ate <br /> Pleasanton <br /> ICA 94588-2704 <br /> PROPERTY OWNER TYPE 1.CORPORATION Lj 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> NN x:ac" .cc a.:.x s vs� ,i1 �„ rA•c' _mss�,y, .:.. _ r. �;Na~ <br /> TANK OWNERNAME 414 PHONE 415. <br /> (925)467-2078 <br /> Safeway Inc. (925) <br /> MAILING OR STREET ADDRESS <br /> 5918 Stoneridge Mall Drive <br /> CITY an. STATE 418.�94588-27� <br /> DE 419. <br /> Pleasanton CA <br /> TANK OWNER TYPE 1.CORPORATION El 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420. <br /> rl 3.PARTNERSHIP 5.COUNTY AGENCY rl 4T 7..FEDERAL AGENCY <br /> W. <br /> dr - oel. <br /> 3 C { ]C <br /> • <br /> TY H 44- 0 4 0 8 0 1 Call 916 322 9669 if eshons arise 421. <br /> 09 <br /> x; <br /> o ''''mac eve a;c� 3 w a _ ,..,•Y-'t „ '.� -�,. - <br /> { w ey <br /> INDICATE METHOD(s) ®1.SbLF-INSURED ❑4.SURHCY BOND ❑7.STATE FUND ❑10.LOCAL OOV'T MECHAMSM 42, <br /> ❑3.INSU�RANCH ❑6.H7�'TIO C�� ❑9.STATE FUND&CD L�� ❑99,OTHER. <br /> &` <br /> C1xck one boz m indicate which address should be used for legal notitkations and a>otling. 423. <br /> Lesal nadficatiotts and tt will be sent>n the tank owner unless box 1«2 is checked. ❑ 1,FACILITY ❑2. PROPERTY OWNER ®3.TANK OWr-ER <br /> r y s.. `..-� :,�•k3i' s...� °'{ n n : �'Y' . .. Y� w.N-'�ys• � ,nx s <br /> s '+. '. >« k b. Ir.+i3aL x.tv 'eC •e <br /> i <br /> it <br /> -;... ..:.rr.!'.. ,.:roe ..... ....... ..... <br /> Certification: I certify Usat the inforantion provided herein is we and wx=te to the beat of my knowledge. <br /> SIGNATURE OF APPLICANT <br /> DATE PHONE 425. <br /> ?,r�< I 1 1 10.08.01 (707)765-1660 <br /> an. <br /> NAME OF APPLICANT(print) 4w• TITLE OF APPLICANT <br /> RM Design Group Inc./Ingmar Walter Job Captain <br /> STATE UST FACILITY NUMBER(Agency-fir) <br /> 429. 1998 UPGRADE CERTIFICATE NUMBER(Agency useodr) az9. <br /> (See Data Element 1,above. <br /> UPCF Awfwr"(1/99)-1/2 httpJlwww.unidocs.org Rev.02/16/00 <br /> �, -d 0026 13rN3SIJ1 dH Wd T S c t, 2002 60 WI C <br />