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PIFIED PROGRAM CONSOLIDATED FO . <br /> UNDERGROUND STORAGE TANK t Z� <br /> OPERATING PERMIT APPLICATION E: -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 /> 3 (Agency Use Only) <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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Unified Grocers, Inc. 323.729.7379 <br /> MAILING ADDRESS 409. <br /> Environmental Health & Safety 5200 Sheila Street <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Commerce CA 90040 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Unified Grocers, Inc. (323) 729.7379 <br /> MAILING ADDRESS 428-3 <br /> Environmental Health & Safety 5200 Sheila Street <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> Commerce I CA 90040 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Unified Grocers, Inc. (323) 729.7379 <br /> MAILING ADDRESS 416. <br /> Environmental Health & Safety 5200 Sheila Street <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Commerce 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 3 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) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTI ATIONertifythat the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLI GN DATE 424. 1 PHONE 425. <br /> 12/9/2009 (323) 729.7379 <br /> APPLICANT N p ' 426 APPLICANT TITLE 427 <br /> Patrick Guillermety Director Environmental Health & Safety <br /> UPCF UST-A Rev.(12/2007) <br />