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C /) itis 1 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# 2 / I' 1 (Agency Use Only) c.J �. BUSINESS NAME(Same as FACILITY NAME or DBA Doing Business As) 3. Pacific Bell Telephone Company dba AT&T California UG010 BUSINESS SITE ADDRESS 103• CITY 104• 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 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 317000 CITY 410• STATE 411• 1 ZIP CODE 412. San Ramon ICA 94583 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. 1 PHONE 428.2 Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 428.3 2600 Camino Ramon-Room 317000 CITY 42844 STATE 428.5 ZIP CODE 428-6 San Ramon ICA 194583 IV. TANK OWNER INFORMATION TANK OWNER NAME: CIO 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 412 1 STATE 418. ZIP CODE 419. Dallas TX 75202 OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 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- 1 0 13 11 19 11 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: 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. 8/1/2008 214 464-3131 APPLICANT NAME(pnn 426. APPLICANT TITLE 427 Steven J. Hall Manager, EH&S UPCF UST-A Rev.(12/2007)