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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 /> (Chock one ISD Only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4m, FACILITY ID 9 _ 1. <br /> 1 /A my Use Oeh) <br /> BUSINESS NAME(Sm..FAaU Y NAIL w WA-Dmg aumw%As) 3 <br /> Pacific Belt Telephone Compagy dba AT&T Califomia UE020 <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 124 W. ELM STREET LODI <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4ot. Is the facility located ore Indian Reservation or 4os <br /> 3.FARM 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4. <br /> Pacific Bell Telephone Company dba AT&T Callfomia 214 5591 <br /> MAILING ADDRESS 404. <br /> 2600 Camino Ramon-Room 3E000 <br /> CITY 410• 1 STATE 411. 1 ZIP CODE 412. <br /> San Ramon CA 94583 <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4211.1• 1 PHONE 4211-2 <br /> Pacific Bell Telephone Company dba AT&T Califomia (214) 5591 <br /> MAILING ADDRESS 4211-3 <br /> 2600 Camino Ramon-Room 3E000 <br /> CITY 4211 4 STATE 128.11 1 ZIP CODE 4211.6 <br /> ` San Ramon CA 94583 <br /> M TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 413. <br /> Pacify Ben Telephone ComMgy dba AT&T Califomia (214)4645591 <br /> MAILING ADDRESS 416. <br /> 2600 Camino Ramon-Room 3Eoo0 <br /> CITY 417. STATE 412. 1 ZIP CODE 419. <br /> San Ramon CA 94583 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42a <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOAM OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- 1 ® 13 11 19 11 1 4 1 Call the State Board of Equalization,Fuel Tax Division,if there aro questions. 421. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and amilings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 473 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4% <br /> APPLICANTVIL SIGNATURE <br /> CERTIFICATION: I that the infotrmaden Provided herein is accurate,and in fall compliance with feed reauirememb. <br /> APPLICANT SIGNATURE DATE 424- PHONE 47-% <br /> 6/3/2008 214 464-3131 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE d27 <br /> Steven J. Hall Manager, EH&S <br /> UPCF UST-A (12/2007) <br />