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Sam, I <br /> IED PROGRAM CONSOLIDATED FORIP <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> 1. FACILITY/SITE INFORMATION. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY <br /> Pacific Bell Telephone Company dba AT&T California <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT' <br /> PACIFIC AVENUE AT&T(UE046) E 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM ®5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 1 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Pacific Bell Telephone Company dba AT&T California 214-464-1929 <br /> MAILING OR STREET ADDRESS 409 <br /> 2600 Camino Ramon, Room 3E000 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION' <br /> TANK OWNER NAME 414 PHONE 415 <br /> Pacific Bell Telephone Company dba AT&T California 214-464-1929 <br /> MAILING OR STREET ADDRESS 41s <br /> 2600 Camino Ramon, Room 3E000 <br /> CITY 417 1 STATE 418 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 /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 13 1 9 1 1 4 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ®3. INSURANCE ❑6. EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <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 ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. 213 1 <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 4z5 <br /> 8/28/2007 - - <br /> N OF APPLICANT(print) 428 TITLE OF APPLICANT 427 <br /> Ja in D. Weller Manager, EH&S <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Sar;Joaquin County,OES <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br /> i <br />