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UE020 <br /> ,0./a <br /> UNIFIED PROGRAM CONSOLIDATED FORM v <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 FACILITY 404' FACILITY ID# _ _ C t. <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME mr 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 ST 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 /> II. 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. ZIP CODE 412. <br /> San Ramon CA 194583 <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 428-4j 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 417. STATE 418. ZIP CODE 419. <br /> 1 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- 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 El4.TANK OPERATOR 423 <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 informs ' n provided herein is true,accurate,and in full compliance with legal requirements.° <br /> APPLICANT SIGNATURE DATE 424. PHONE <br /> 425. <br /> 9/29/2011 (214)464-3131 <br /> Off <br /> APPLICANT NAME(pri L0.0, 426. APPLICANT TITLE '"X27 <br /> Steven J Hall Manager, EH&S <br /> UPCF UST-A ' Rev.(12/2007) <br />