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IED PROGRAM CONSOLIDATED FO <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. FACILITYINFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 14, <br /> `�(Agency Use Only) / <br /> BUSINESS NAME(Same as FACILITYNAME or DBA-Doing Business As) 3. <br /> Grupe Commercial Company <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 5000 South Lindergh Street Hanger 2 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 /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> County of San Joaquin (209)468-4700 <br /> MAILING ADDRESS 409. <br /> 5000 South Airport Way,Room 202 <br /> CITY 410. STATE411. ZIP CODE 412. <br /> Stockton CA 95206 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Grupe Commercial Company (209)473-6200 <br /> MAILING ADDRESS 428-3 <br /> 3255 West March Lane, Suite 400 <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> Stockton CA 95219 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Grupe Commercial Company (209)473-6200 <br /> MAILING ADDRESS 416. <br /> 3255 West March Lane, Suite 400 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Stockton CA 95219 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 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- 1 0 1 4 1 8 1 9 1 6 1 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: [11.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 /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICAN IGNAT1dRE DATE 424. PHONE 425. <br /> f� 1141 U-F� Z) 11-- (209)473-,62(kl <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Maurice Liu Vice President <br /> UPCF UST-A Rev.(12/2007) <br />