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(7) 1 /zjic_yj UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ I.NEW PERMIT ® 5.C 1-IANGE OF INFORMATION ❑ 7.PERMANENT FACILITYCLOSURE 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 FACILTfY ID# _ 1 64gencv Use Only) BUSINESS NAME(Sant as FACILITY NAME.,DBA-Doing Boss As) J Pacific Bell Telephone Company dba AT&T California UE046 BUSINESS SITE ADDRESS 101 CITY 104. 907 LINCOLN ROAD STOCKTON FACILITY TYPE ❑ I.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 MAILING ADDRESS 409 2600 Camino Ramon- Room 3E000 CITY 410. STATE 411, 1 ZIP CODE 412. San Ramon I CA 94583 M. TANK OPERATOR INFORMATION TANK OPERATOR NAME. 428-1. PHONE 428-2 Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 42a-J 2600 Camino Ramon- Room 3E000 CITY 428-4 STATE 428.5 ZIP CODE 428'6 San Ramon ICA 1 94583 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415 Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 4i6 2600 Camino Ramon- Room 3E000 CITY 417 STATE 418, ZIP CODE 419. San Ramon CA 94583 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- J 0 13 11 19 1 1 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: ® L 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: f certify that the Information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424 PHONE 425. 6/3/2008 214 464-3131 APPLICANT NAME(print) a26 APPLICANT TITLE 427 Steven J. Hall Mana er, EH&S U PCF us'r-A (12/2007)