Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ T PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.'TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 'TOT'AL NUMBER OF USTs AT FACILITYFACILITY ID# _ t <br /> 404. <br /> 1 (Agencv Use Onit) <br /> BUSINESS NAME(S;vne 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 ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405 <br /> 3.FARM 0 4.PROCESSOR Z 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 u1o. STATE 411 ZIP CODE 412. <br /> San Ramon CA 94583 <br /> M. 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 TSTATE 428-5 ZIP CODE 428.6 <br /> San Ramon ICA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> Pacific Bell Telephone Company dba AT&T California (214)464-5591 <br /> MAILING ADDRESS 416 <br /> 2600 Camino Ramon—Room 3E000 <br /> CITY 417 STATE 418 1 Z.IPCODE 4iQ. <br /> San Ramon CA 94583 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.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 13 11 19 11 1 4 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> V1.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: Z 1.FACILITY OWNER ❑ 4.TANK OPERATOR 4`3 <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 re uirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425 <br /> 6/3/2008 214 464-3131 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 4'--7 <br /> Steven J. Hall Manager, EH&S <br /> U PCF UST-A (12/2007) <br />