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l <br /> Cr <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 ® S.CHANGE-OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4W' <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 FACILITY ID# <br /> 1 (dgencv Use Onit) <br /> BUSINESS NAME(Same as FACILITY NAME o,DBA-Doing Business As) 3 <br /> Pacific Bell Telephone Company dba AT&T California UE046 <br /> BUSINESS SITE ADDRESS 103, CITY 104, <br /> 907 LINCOLN ROAD STOCKTON <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands'? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> Pacific Bell Telephone Company dba AT&T California 214 464-5591 <br /> MAILING ADDRESS 409 <br /> 2600 Camino Ramon— Room 3E000 <br /> CITY 410 STATE 411, 1 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> Pacific Bell Telephone Company dba AT&T California (214)464-5591 <br /> MAILING ADDRESS 428.3 <br /> 2600 Camino Ramon— Room 3E000 <br /> CITY 4284STATE 428.5 ZIP CODE 428.6 <br /> San Ramon I CA 194583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Pacific Bell Telephone Company dba AT&T California (214)464-5591 <br /> MAILING ADDRESS 416. <br /> 2600 Camino Ramon— Room 3E000 <br /> CITY 417,1 STATE 418. ZIP CODE 419, <br /> San Ramon CA 94583 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 13 11 19 11 1 4 1 Call the State Board of Equalisation,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® I.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 cerdfy that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425 <br /> 6/3/2008 214 464-3131 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 42 <br /> Steven J. Hall Manager, EH&S <br /> UPCF UST-A (12/2007) <br />