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0/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILI'T'Y INFORMATION <br /> (One form par facility) <br /> TYPE OF ACTION ❑ I.NEW PERMtr, ® 5.CRAIVGE OF INPOnfA,TION ❑ 7,PERMANENT FACaXfY CLDSURE 400. <br /> {Ckedco7fey7emonly) ❑ 3.RENEWALPERM1T <br /> ❑ 6.TEMPORARY FAC.CL,ITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> FACMr INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 404 7ACU= <br /> ID <br /> 3 (Asen-cy Use Qnty) L±i I <br /> ESS NAME(Sams esFacidi?yNams or DBA-Ddmg$us3nfssAs) 3. <br /> BONFARE MARKET##35 <br /> Y3[J811 SS SITE ADDRESS 103. Oar 104. <br /> 15 E. GRANT LINE RD. TRACY <br /> PAC1L n Y TYPE 0 1,MOTOR VEHICLE PLTEI ANG ❑ 2-FUEL DISTRIBUTION ao3, � Is the fwilitY located on Indian Reservation or 405. <br /> El3.FARM ❑ 4_PROCESSOR ] d,OTI;TR , Trust lauds? ❑ 1.Yes ® 2.No <br /> > kitOPERTY O�VVNER IN -HON <br /> PROPERTY OWNER NAME 07• f PRONE 409. <br /> SALLABERRY FAMILY TRUST 1650 322-3285 <br /> MAnJNG ADDRESS 4 4. <br /> 1735 CRONER AVE <br /> Crry 410. 1 STATE 411. 2IP CODE 412. <br /> MENLO PARK CA 94025 <br /> M. TANK'QPERATOR'Y1�FFQIi�ATIt7►N <br /> -TANK OPERATOR NAME x26-1. PHONR 4ai.2. <br /> NIK ZAGOROV (415)74th-8590 <br /> MAU,ING ADDRESS aaa-3. <br /> IP0 BOK 77194 <br /> CdTY 42&4 STATE Szes. <br /> ice'CODE ozs-0. <br /> i SAN FRANCISCO CA 94107 <br /> ? TANK-O'VYMEWINXORMA <br /> TANK OWNER NAME 414. PHp 415. <br /> BONFARE MARKETS INC (408)$74_8600 <br /> MA93NG ADDUSS 416. <br /> 461 SOUTH MILPITAS BLVD <br /> C1= 417- 1 STATE o1a. _ZIPCODE 419. <br /> MILPITAS • C:A 95035 <br /> O`ANER TYPE: C] 4.LOCA AGENCY/DISTRZCT ❑ 5.COUN'T'Y ACTENCY ❑ 6.ST TL AGENCY 420. <br /> ❑ 7 FE>18RAL AGENCY ® 8.NON-GOVERNTMENzT <br /> �. B4tRT1 tDFQI7AII7,A TIUN US x �iTORAGEE ACCUUNT NUI418ER <br /> Ty )HQ 44- Callthe 8We Board of$quahZatioa,Fuel T=DiVisiM i1f'theso arc gu esgtotlS. Sz1. <br /> _ . . PERNII it 4LDI+1R WORMAT10N , <br /> Issue permit,and se*4 legal natificatiQns and mailings to. ❑ I-PACILIT Y OWNER ❑ 4.TANK OPERATOR 4.3. <br /> ® 3.TANK O'OIrNtR ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DTViSION,88GTION.OR OITFICE{Required for Pubtic Ager+ci�s Cmiy} SQ6, <br /> VII.AP)MICANT SIGNATURE <br /> C.ERTMC.A,TYON: I eery thatnnforntstiapaprovided I;a[ein is true accara clad in full c7o�tq 1lance wltt l en <br /> APPL�51c1NATUR" DATE 424, PHONE 425. <br /> 12/1/2011 Ir510 84-8457 <br /> APPLICANT NAME(priw) 42,1- APPLICAN'''T'TITLE p 427 <br /> RUSS MCLEOD AREA DIRECTOR <br /> ■TAW-'V YtCl AD- HJIINM'TTEG-3 ZTO/LOOd 88L-1. 8L95-EZT-80� sas-ijdi9juH .zoodeli-WOd3 5Z:9T TT,-50-ZT <br />