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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 /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITYFACILITY ID# <br /> 1 ' (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> Pacific Bell Telephone Company dba AT&T California UE020 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 124 W. ELM STREET LODI <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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> Pacific Bell Telephone Company dba AT&T California 214 464-5591 <br /> MAILING ADDRESS 409• <br /> 2600 Camino Ramon -Room 3E000 <br /> CITY 410• STATE 411• 1 ZIP CODE 412. <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Pacific Bell Telephone Company dba AT&T California (214) 464-5591 <br /> MAILING ADDRESS 428-3 <br /> 2600 Camino Ramon -Room 3E000 <br /> CITY 428-4 1 STATE 428-5 ZIP CODE 428-6 <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME C/O AT&T EH&S 414. PHONE 415, <br /> Pacific Bell Telephone Company dba AT&T California (214) 464-5591 <br /> MAILING ADDRESS 416. <br /> 308 S. Akard Street, Room 1700 <br /> CITY 41 STATE 418. ZIP CODE 419. <br /> Dallas TX 75202 <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- 0 13 11 9 11 1 4 F 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 /> VTI.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that th formation provided herein is true accurate and in full compliance with legal re uirements. <br /> APPLICANT SIGNATURE DATE 424• 1 PHONE 425. <br /> 2/2/2009 (214)464-3131 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> Steven J. Hall Mana er, EH&S <br /> UPCF UST-A (12/2007) <br />