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VP7D PROGRAM CONSOLIDATED FIC <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 1(new tank) <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 40e• <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> .:....:::..:.:..:..... ....::.;::::: ;:::- >::>;::::::; %. lii1;JJ.r1�. :�RLY1Al�:s:. <br /> BUSINESS NAME Same asFAciLrryN- .o.D-.- <br /> AME r DBA- As����� <br /> FACILITY <br /> ILTTI',,,,,• <br /> Doing ) 3. <br /> Pacific Bell ID# ' <br /> NEAREST CROSS STREET4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 4R. <br /> ElPortal ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS Ej 1.GAS STATION ❑3.FARM ®5.COMMERCIAL 403• [:12.INDIVIDUAL [16.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404• Is facility on Indian Reservation 405• •If owner of UST is a public agency:name of supervisor of division,section or 406• <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> One diesel tank ❑Yes ®No <br /> :.....:::.:.:...::.:..::..:::::.:.-::..::::..:..:;;...;... . .. . <br /> :::::<:;:;:;::::::-:.::.:::.:::::::<::.::.::;:: . :::::::::::::::::;<:.;gR`'€ PROP .. <br /> X. <br /> ::�7:::: <br /> PROPERTY OWNER NAME <br /> PHONE 408. <br /> Pacific Bell 877-823-9833 <br /> MAILING OR STREET ADDRESS 409, <br /> 2600 Camino Ramon,Rm. 3E000K <br /> CITY 410. STATE 411• ZIP CODE 412. <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> ::;:;:::::....:::::::...::::::::.:::..:::<::<::<::<::<::::<:::::;i:;:::::::::::::.::::::::::.::;:.; kk-k..:J:; r <{i� -kms. N.A• t7iTaLQ :::-.;:::::.>:.:i:-.:.::-.::-r:-:.. >::.::.::;;:.;:::;::s::::.:::.>->:-.;: <br /> TANK OWNER NAME <br /> ...................... <br /> .....................................................................................:......................:...:....:.::::.::::.::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::. <br /> 414. PHONE ats. <br /> Pacific Bell 877-823-9833 <br /> MAILING OR STREET ADDRESS 416. <br /> 2600 Camino Ramon,Rm. 3E000K <br /> CITY 417. STATE Ota. ZIP CODE 419. <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> `:. <br /> :.::..-..:.... <br /> .......:.....:;;;;::::::::-<::::. ::.: F ::A CO NT.. tLlil'IEET:.:;.:...:..::.:.::::::: ::>:::::;::;: <br /> :..:.:...:.:::::. :..::. :.::_:.:::::.::.:.�::..:::.::...........:....:::::.....:........................................-..............................................................................................._.. <br /> TY <br /> ................::::::H:::::44-::::: _ <br /> 0:::::::.3 :::::1::::::::9:::::. ::.;:.;:916:::::.:: <br /> 1:::::::4:::::: :: Call 322-9669 if questions arise ::: 421. <br /> .:......... ...:.:... <br /> ::::: :;......... % ::::::.:::::: <br /> ..PEROL1r. Ll <br /> ......... .; <br /> .......:::.... ; .... _.. ......... ....... iIVL.... '.)'iN .3tE�r�`P N B TY......::...:...............:..; '>[:>':: ...............-.............. <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12 GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> ..:. <br /> . .... . <br /> ... .. :: .:..::: ..:. <br /> . <br /> ............... . :: s: <br /> :> x xc TxO c.AN> . r N .ADD -SS--' ::.::.:::..::::.::.:::.................. <br /> :...::............ ........:<:..:.::::.:.......:::.: <br /> :. I. :..........:..-..:. <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY 02. PROPERTY OWNER ❑3.TANK OWNER 423• <br /> :ai:r>:e;r::::i::>=>::;»:::a:..E:E?:i : ':: 7 ...i�l #:ru� e�7tT.r �T ? : .i>':`:`EEEE' .':... :.:.. <br /> ..................................................................................................................................... <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424• PHONE 425. <br /> 707-765-1660 <br /> NAME OF APPLICANT(print) 426• TITLE OF APPLICANT 427. <br /> Scott Tannehill Agent for Pacific Bell <br /> STATE UST FACILITY NUMBER(Agencyuse only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency-only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.wddocs.org Rev.02/16/00 <br />