COMPLIANCE INFO_2003-2011 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 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# 1 (Agency Use Only) BUSINESS NAME(Sarne as FACILITY NAME or DBA-Doing Business As) 3. Pacific Bell Telephone Company dba AT&T California UG010 BUSINESS SITE ADDRESS 103. CITY too. 1812 COLEY AVE ESCALON FACILITY TYPE ❑ 1.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 H. 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 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 ,O TION 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. 1 ZIP CODE 419. Dallas TX 75202 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY 0 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST'STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 ® 13 11 19 1 1 1 4 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 423 p g g ❑ ❑ 4.TANK OPERATOR 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 re uirements. APPLICANT SIGNATURE DATE 424• 1 PHONE 425• 5/14/2009 (214)464-3131 APPLICANT NAME(print) 426. APPLICANT TITLE 427 Steven J. Hall Manager, EH&S UPCF UST-A Rev.(12/2007)