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WIED PROGRAM CONSOLIDATED F <br /> KS <br /> X o- <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Pag 1 of 7 <br /> TYPE OF ACTION ® L NEW SITE PERMIT [13.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED S D3 <br /> (Checkoneitemonly) ❑4.AMENDED PERMIT specify change local use only ❑ e.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE <br /> I. FACILITY/ SITE INFORMATION (� <br /> BUSINESS NAMES.as FACILITY NAME or DSA-Doing Susinesa As) 3 FACILITY ID# <br /> Safeway Store#2707-6425 Pacific Ave. Stockton Dot <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT.*^^ (� <br /> DOU las Road ® 1.CORPORATION [15.COUNTY AGENCY- <br /> I <br /> BUSINESS ® 1.GAS STATION ❑3.FARM [15. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> 1 LLLI <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:Dame of supervisor of division,section or office whi <br /> REMAINING AT SITE trustlends? operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 4a <br /> J` 13 I O II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SAFEWAY,INC. 925 467-2217 <br /> MAILING OR STREET ADDRESS 400 <br /> 5918 STONERIDGE MALL ROAD <br /> CITY 410 STATE 611 ZIP CODE 412 <br /> PLEASANTON CA 94588-2704 <br /> PROPERTY OWNER TYPE N 1.CORPORATION ❑2.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAFEWAY STORES,INC./FUEL STATION OPERATIONS MANAGER 925 467-2217 <br /> MAILING OR STREET ADDRESS 416 <br /> 5918 STONERIDGE MALL ROAD <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> PLEASANTON CA 94588-2704 <br /> TANK OWNER TYPE N 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- 1 0 4 0 8 0 1 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <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 APP T DATE 424 1 PHONE 425 <br /> ?-"0 <br /> J0`I�//) 1/ <br /> g/,m (925)467-2078 <br /> �T <br /> NAME OF APPLICT(print) 426 TITLE OF APPLICANT 420 <br /> Todd Paradis "N0,60 Ra AAW S Real Estate Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Far local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />