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UNIDOCS <br /> FACILITY INFORMATION <br /> BUSINESS OWNER/OPERATOR IDENTIFICATION <br /> I. IDENTIFICATION <br /> FACILITY ID# 1_11_11. BEGINNING DATE 100, ENDING DATE 101. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. BUSINESS PHONE Im. <br /> S-Mart#91 209 334-6853 <br /> BUSINESS SITE ADDRESS 103. BUSINESS FAX ioh <br /> 610 West Kettleman Lane 209 334-1254 <br /> BUSINESS SITE CITY 104 ZIP CODE 105. COUNTY Ioe. <br /> Lodi CA 95240 San Joaquin <br /> DUN&BRADSTREET 106. PRIMARY SIC im. PRIMARY NAICS 10"h. <br /> 007874480 5411 <br /> BUSINESS MAILING ADDRESS 1081, <br /> 1800 Standiford Ave <br /> BUSINESS MAILING CITY 1086. STATE lag= I ZIP CODE 1086. <br /> Modesto CA 95350 <br /> BUSINESS OPERATOR NAME IN BUSINESS OPERATOR PHONE 110. <br /> Save Mart Supermarkets (209) 577-1600 <br /> II. BUSINESS OWNER <br /> OWNER NAME 111. OWNER PHONE 112. <br /> Save Mart Supermarkets (209) 577-1600 <br /> OWNER MAILING ADDRESS 113 <br /> 1800 Standiford Ave <br /> OWNER MAILING CITY 114. STATE 115. Z]PCODE Ile. <br /> Modesto CA 95350 <br /> III. ENVIRONMENTAL CONTACT <br /> CONTACT NAME 117. CONTACT PHONE 118. <br /> Sherry Aebersold 209 548-6569 <br /> CONTACT MAILING ADDRESS 119. CONTACT EMAIL I19s <br /> 1800 Standiford Avenue saebersold@savemart.com <br /> CONTACT MAILING CITY 120. 1 STATE 1211 ZIP CODE 122. <br /> Modesto CA 95350 <br /> -PRIMARY- IV. EMERGENCY CONTACTS -SECONDARY- <br /> NAME 123. NAME 12s. <br /> Larry Malone DennyWraske <br /> TITLE 124. TITLE 129. <br /> Store Manager Sr. Director of Operations <br /> BUSINESS PHONE 125. BUSINESS PHONE Iia <br /> 209 334-6853 209 548-6608 <br /> 24-HOUR PHONE 126. 24-HOUR PHONE 131. <br /> 209 247-7557 209 484-2333 <br /> PAGER# 12Z PAGER# 132. <br /> N/A N/A <br /> ADDITIONAL LOCALLY COLLECTED INFORMATION: 133. <br /> Certification: Based on my inquiry of those individuals responsible for obtaining the information,I certify under penalty of law that I have personally examined and <br /> am familiar with the information submitted and believe the information is true,accurate,and complete. <br /> SIG URE OF ER/OPERATOR OR DESIGNATED REPRESENTATIVE DATE 134. NAME OF DOCUMENT PREPARER 135. <br /> , 13,7,:9 Billie Gravano <br /> N S N print 136. TITLE OF SIGNER 13]. <br /> S r Aebe sol Director Of Compliance/ISO <br /> S-Mart#209 Page 2 of 16 March 2011 <br />