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UNIFIED PROGRAM CONSOLIDATED FORM 6 f g /O <br /> UNDERGROUND STORAGE TANK 1 <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATIONKX <br /> (One form per facility) (� <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY D# <br /> 2 (Agency Use Only) y <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Safeway Fuel Station 2707-10 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 6425 Pacific Ave. Stockton . <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 403" <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes M 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401. PHONE 40a <br /> Safeway Inc. 925) 467-3000 <br /> MAILING ADDRESS 409. <br /> 5918 Stonerdi a Mall Rd. <br /> CITY 410. STATE 411, 1 ZIP CODE 412. <br /> Pleasanton Ca 94588-3229 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATORNAME 428-1. PHONE 428-2. <br /> Safeway Inc. (925) 467-3000 <br /> MAILINGADDRESS 428-3. <br /> 6000 Stoneridge Mall Rd. / P.O. Box 9070 <br /> CITY 4284. 1 STATE 428b. ZIP CODE 428x. <br /> Pleasanton Ca 94588-3229 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. 1 PHONE 413. <br /> Safeway Inc. (925) 467-3000 <br /> MAZING ADDRESS 416. <br /> 6000 Stoneridge Mall Rd. / P.O. Box 9070 <br /> CITY 417. STATE 418. ZIP CODE 419• <br /> Pleasanton Ca 94588-3229 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1014 10 18 1 0 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 486. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurat and in full compliance with le al requirements. <br /> APPLICAMEATURE DATE 424. 1 PHONE, 423. <br /> 6/4/2009 925 4 -7164 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE .,. 4 427 <br /> Butch Hobson Safety and Env. Affairs M r q�r, <br /> UPCF UST-A Rev.(I2/2007)-1/2www.unidocs.org {ml� Y5&�"' <br />