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UNIFIED PROGRAM CONSOLIDATED FORM �7 <br /> UNDERGROUND STORAGE TANK r� <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIO1r/ <br /> V41 (v <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 19 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Cbeckmm dent only) ❑ 3.RENEWAL PERMIT <br /> ❑ G.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY 1D it <br /> 3 (Agency Use Only) 3 <br /> BUSINESS NAME(Same as Facility Nanle or DBA-Doing Business As) 3, <br /> Rale 's Aisle 1 #356 <br /> BUSINESS SITE ADDRESS 103. CITY lm <br /> 4219 Morada Lane Stockton <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 903' Is Ute facility located on Indian Reservation or 4os. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40'r. PHONE 408. <br /> Raley's Family of Fine Stores 916 373-3333 <br /> MAILING ADDRESS <br /> 409. <br /> 500 West Capitol Ave. <br /> CITY 410_ STATE 4u. ZIP CODE 412. <br /> West Sacramento CA 95605 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 4282. <br /> Rale 's Family of Fine Stores (916) 373-3333 <br /> MAILING ADDRESS 428.3. <br /> 500 West Capitol Ave. <br /> CITY 4284 1 STATE 428-3. ZIP CODE 42&6. <br /> West Sacramento CA 95605 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Rale 's Family of Fine Stores (916) 373-3333 <br /> MAILING ADDRESS 416, <br /> 500 West Capitol Ave. <br /> CITY 417. 1 STATE 418. I ZIP CODE 41% <br /> West Sacramento CA 95605 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10141 1 11 161 9 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 notificatimis and mailings to: 2 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423' <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required jar Public Agencies Only) 406. <br /> "ta <br /> VII. APPLICANT SIGNATURE - =- <br /> CERTIFICATION: I cpAffy that the information provided herein is true,accurate and in full compliance with legal re uiremen i <br /> APPLICANT SIGNATURE DATE 424 PHONE= �; 42s. <br /> 7/17/2009 916) 376-6679 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4n <br /> Paul Gianetto Sr. Manager Outside Sales <br /> ,y <br /> UPCF UST-A Rev.(122007)-12 www.unidocs.org completed <br />