COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

UE042 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (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# _ E 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. PHONE 408. Pacific Bell Telephone Company dba AT&T California 214 464-5591 MAILING ADDRESS 409. 2600 Camino Ramon - Room 3E000 CITY 410 STATE 411. ZIP CODE 412. San Ramon CA 94583 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME Q28-1. PHONE 428-2 Pacific Bell Telephone Company dba AT&T California (214) 464-5591 MAILING ADDRESS 428-3 2600 Camino Ramon - Room 3E000 CITY 428-4 1 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 420, ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 ® $ 1 1 19 1 1 1 4 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: ® L FACILITY OWNER El4.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 information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE 3-- DATE 424. 1 PHONE 425. 9/20/13 (214) 464-2847 APPLICANT NAME(print) 426. APPLICANT TITLE 427 Lynn Hunt Manager, EH&S UPCF UST-A Rev.(12/2007)