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n <br />UNIFIED PROGRAM CONSOLIDATED FORM <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• <br />FACILITY ID # <br />1 <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3. <br />AT&T Corp. UE231 <br />BUSINESS SITE ADDRESS 103• <br />CITY 104. <br />J110 W. TURNER RD. <br />LODI <br />FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403 <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ® 6. OTHER <br />Trust lands? ❑ Yes ® No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Pacific Bell Telephone Company dba AT&T California <br />1 214 464-5591 <br />MAILING ADDRESS 409. <br />2600 Camino Ramon - Room 3E000 <br />CITY 410. <br />STATE 411• <br />ZIP CODE 412. <br />San Ramon <br />CA 1 <br />94583 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1• <br />PHONE 428-2 <br />Pacific Bell Telephone Company dba AT&T California <br />(214) 464-5591 <br />MAILING ADDRESS 428-3 <br />2600 Camino Ramon - Room 3E000 <br />CITY 428-4 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />San Ramon I <br />CA <br />94583 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />AT&T CorpC/O AT&T EH&S <br />(214) 464-5591 <br />MAILING ADDRESS 416. <br />308 S. Akard Street, Room 1700 <br />CITY 41 <br />STATE 418. <br />ZIP CODE 419. <br />Dallas <br />TX <br />75202 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY S9 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 0 14 14 19 16 1 ® 1 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 ❑ 4. 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 information provided herein is true accurate and in full compliance with legal requirements. <br />APPLICANT SIGNATURE <br />DATE 424. <br />PHONE 425. <br />4/30/2009 1 <br />(214) 464-3131 <br />APPLICANT NAME (print) 426• <br />APPLICANT TITLE 427 <br />Steven J. Hall <br />Manager, EH&S <br />UPCF UST -A (12/2007) <br />