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III <br /> U ED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT N 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑67EMPORARY SITE CLOSURE 400 <br /> I. 'FACILITY./,SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY <br /> Pacific Bell Telephone Company dba AT&T California ' 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> NORTH CHURCH ST AT&T(UE020) N 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM N 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 1 404 ❑ Yes N No 405 406 <br /> I! RR ?PRT <br /> Y OWNER INFORMATION <br /> .., •:., ,;Vis. ,_ ,-w. .... .: .. ... - ..,,, ,. <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Pacific Bell Telephone Company dba AT&T California 214-464-1929 <br /> MAILING OR STREET ADDRESS 409 <br /> 2600 Camino Ramon, Room 3E000 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION [12 ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP 1715.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III,TANK(3'WNERINFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Pacific Bell Telephone Company dba AT&T California 214-464-1929 <br /> MAILING OR STREET ADDRESS 416 <br /> 2600 Camino Ramon, Room 3E000 <br /> CITY 417 STATE 41a ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE N 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATIONUST:STORAGE FJEE ACG(? NT NUMBER <br /> TY TK HQ 44- 0 3 1 9 1 4 Call 916 322-9669 if questions arise 421 <br /> Y PETRQLEUM USS"FINANCIAL RESPONSIBILITY <br /> INDICATE 17711.SELF-INSURED [14.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) [:12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> N 3. INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI LEGAL NOTIFICTIcN: ND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notificationsy <br /> and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER N 3.TANK OWNER 423 <br /> �tll ADPL IOANT SIGNATURL� .. <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> 8/28/2007 707-765-1660 <br /> NA OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Jason D. Weller Manager, EH&S <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Sar.Joaquin County,OE:S <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />