Laserfiche WebLink
73 v3 <br /> PWIFIED PROGRAM CONSOLIDATED F <br /> TANKS <br /> a� <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page I of l(removal) <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE ap. <br /> (Check one item only) (14.AMENDED PERMIT (Specify change) ®8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sone u FACILITY NAME or DBA-Wing Bmineu As) 3. 1 FACILITY <br /> Pacific Bell IDM S <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 72 <br /> East 6th Street ® I.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS ❑ 1.GAS STATION [13.FARM ®5.COMMERCIAL ao3. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation 4a5. *If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or hist lands? office which operates the UST. (This is the contact person for the tank records.) <br /> One diesel tank ❑Yes ®No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407- PHONE 409. <br /> Pacific Bell 877-823-6161 <br /> MAILING OR STREET ADDRESS 409. <br /> 2600 Camino Ramon,Rm.3E000K <br /> CITY 4r0. STATE 411. ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 425, <br /> Pacific Bell 877-823-6161 <br /> MAILING OR STREET ADDRESS 416. <br /> 2600 Camino Ramon,Ron. 3E000K <br /> CITY 417. 1 STATE 419. ZIP CODE 419. <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 3 1 1 1 9 1 1 4 1 Call 916 322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER [13.TANK OWNER 423- <br /> VII. <br /> vVII. APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIORA17URE OF APCLICALqT DATE 424 PHONE 425. <br /> -Z-DZ 707-765-1660 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Scott Tannehill Agent for Pacific Bell <br /> STATE UST FACILITY NUMBER(Agency u only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency are only) 429. <br /> (See Data Element 1,above. <br /> UPCF HW(wrc.a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />