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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <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 ID# _ _ i. <br /> 1 (Agency Use Only) I F1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Unified Grocers, Inc. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1990 Piccoli Road Stockton <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑ 1.Yes Z 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Unified Grocers, Inc. (323) 264.5200 x8648 <br /> MAILING ADDRESS 409. <br /> 5200 Sheila Street Attention: Environmental Health & Safety <br /> CITY 417 STATE 411. ZIP CODE 412. <br /> Commerce CA 90040 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2. <br /> Unified Grocers, Inc. (323) 264.5200 x8648 <br /> MAILING ADDRESS 428-3. <br /> 5200 Sheila Street Attention: Environmental Health & Safet <br /> CITY 4284. STATE 428-5. ZIP CODE 428-6. <br /> Commerce CA 90040 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME a14. PHONE 415. <br /> Unified Grocers, Inc. (323) 264.5200 x8648 <br /> MAILING ADDRESS 416. <br /> 5200 Sheila Street Attention: Environmental Health & Safety <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> Commerce I CA 90040 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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- 10 10 7 7 3 1 8 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: El1.FACILITY OWNER Z 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTJT1j5kT101%,VUertify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APP L S DATE 424. PHONE 425. <br /> 12/24/2008 (323) 264.5200 x8648 <br /> APPLICANT E t) 426. APPLICANT TITLE 427 <br /> Patrick Guillermety Director, Environmental Health & Safety <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />