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UE042 LSF UNIFIEDUNDE GROUNDS ORAGE TANK SOLIDATED ORM \� ! ri?t OPERATING PERMIT APPLICATION-FACIL8FORMATION 1 ` �.,J (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ _ I. 1 (Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA Doing Business As) 3. Pacific Bell Telephone Company dba AT&T California UE042 BUSINESS SITE ADDRESS 103. CITY 104. 345 N. SAN JOAQUIN ST. STOCKTON FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑Yes ®No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. 1 PHONE 408. Pacific Bell Telephone Company dba AT&T California 214 464-5591 MAI G ADDRESS 409. 2600 Camino Ramon -Room 3E000 C,j.T_Y 410. 1 STATE 411. 1 ZIP CODE 412. San Ramon CA 94583 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 428-3 2600 Camino Ramon -Room 3E000 CITY 4284 STATE 428-5 ZIP CODE 428-6 San Ramon � CA 94583 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 416. 308 S. Akard St. Room 1700 CITY 417. 1 STATE 418. ZIP CODE 419. Dallas TX 75202 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 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. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ED 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the informs ' n provided herein is true,accurate,and in full compliance with legal requirh vents. APPLICANT SIGNATURE DATE 424. PHONE 425. 5/14/2010 (214)464-313t APPLICANT NAME(print 426. APPLICANT TITLE F 427 Steven J Hall Manager, EH&S Com oln UPCF UST-A Rev.(12/2007)