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Mar 19 04 11 : 22a RHL =sign Group (925' x13-9709 p. 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page of <br /> TYPE OF ACTION ® 1.NEW s1TE PERMIT ❑3.RENEWAL PERMr ❑5.CNANGE OF INFORMATION ❑ 7FERMANENTLY CLOSED SITF. <br /> (Clwck one item only) ❑4.AMENDED PERMIT specify clmngc local use only ❑ 8,TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAM E(s.u FAaurY NAME w DRA-Doing Eurmemas) 3 FACtWTY IDN <br /> Safeway Store#2707-6425 Pacific Ave.,Stockton <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT* <br /> Douglas Road ® 1.CORPORATION ❑S.COUNTY AGENCY" <br /> BUSINESS lQ L GAS STATION ❑3.FARM F1 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 [13.PARTNERSHIP ❑7.FEDERAL AGENCY* 462 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'IfownerofUSf is o public agency:amrm orsuµ:rvisurofdivlsion,scommaroRec which <br /> REMAININGATSITE Rustlands7 operates dre LET(nus is the contact person for the tank records.) <br /> 3 iM ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SAFEWAY,INC. _ (925)467-2217 <br /> MAILING OR STREET ADDRESS 409 <br /> 5918 STONERIDGE MALL ROAD <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PLEASANTON CA 94588-2704 <br /> PROPERTY OWNER TYPE N LCORPORATION 2.INDIVIDUAL Lj 4.L.00ALAGENCY/DISTRICT ❑6.STATEAGENCY <br /> ❑3.PARTNERSHIB' [:IS.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> M.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414PFIONE 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 ar STATE 418 ZIP CODE 419 <br /> PLEASANTON __ CA 94588-2704 <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 4 0 8 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 ❑ L0.LOCAL GOVT'MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 4" <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to irdieme which address slmuld be used for legal notifiwtins and mailing. <br /> Lcgvl wtific6tioas and nmilings will be.scut b cM1e unk owner mdess hax 1 erg u checked ❑ L FACILITY [12, PROPERTY OWNER 03.TANK OWNFR +22 <br /> VII. APPLICANT SIGNATURE <br /> Cenirwation-1 certify that the infornr45on provided herein is true and accurate to the best of my lomwledge. <br /> SIGN`ATUR.EOIFAPPLI T DATE 4a+ PHONE 435 <br /> I�'o(A I 316 1 (925)467-2078 <br /> NAME OF APPLICA (print) +u TITL OF APPLICANT 4n <br /> Todd Paradis a Real Estate Manager <br /> STATE UST FACILITY NUMBER(For ioatmeomy) 423 1998 UPGRADE CERTIFICATE NUMRFR nw i-i.e May) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />