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vI IFIED PROGRAM CONSOLIDATED FO r. UNDERGROUND STORAGE TANK �1 OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facili ) TYPE OF ACTION E] 1.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# p. 1 1 (Agency Use Only) 3 1Q Q BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3' Pacific Bell Telephone Company dba AT&T California UE046-SKTNCAll BUSINESS SITE ADDRESS 103. CITY 104. 907 LINCOLN RD STOCKTON FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR N 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 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 428-4 1 STATE 428-5 ZIP CODE 428-6 San Ramon CA 94583 IV. TANK OWNER INFORMATION TANK OWNER NAME C/O AT&T ENVIRONMENT HEALTH&SAFETY 414. PHONE 415. Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 416. 308 South Akard Street Room 1700 CITY 417. 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- LO-J-3f-11911141 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: ❑ 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 information provided herein is true accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424. 1 PHONE 425. July 28, 2008 214 464-3131 APPLICANT (print) 1.7 426• APPLICANT TITLE 427 Steven J Hall Manager, EMS UPCF UST-A Rev.(12/2007)