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Sent By: RHL DESIGN GROUP; 7077654503; Jun-19-02 8:07AM; Page 2/4 <br /> ' L: ED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page I of 1(removal) <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one mm,Only) ❑4-AMENDED PERMIT(Specify change) ®R TANK RrMOVED <br /> ❑e.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS NAME I,S m.a FAaLIW NAMe or DOA M,R* inm As) 3, FACILITY <br /> Pacific Bell ON <br /> NEAREST CROSS STREET 4t. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT <br /> ' East 6th Street ®1.CORPORATION ❑5.CouwrY AGENCY' <br /> BUSINESS 0 1.GAS STATION (13.FARM ®5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7 FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS aw. Is facility on Indian Reservation 405. •If owner of UST is a public agency:offne of mpervlsa of divfslon,sectiat or 496. <br /> REMAINING AT SITE or trust lands:' of ice wNch operates the UST. (This is the m=t petsm for he mnk reeords.) <br /> ' One diesel tank ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMEJ01 PHONE 4a. <br /> Pacific Bell 877-823-6161 <br /> MAILING OR STREET ADDRESS 4ot <br /> 2600 Camino Ramon,Rm.3E000K <br /> CITY 41 e. STATE 411. ZIPCODE 432. <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPEI.CORPORATION ❑2.NDIVIDUAL ❑4.LOCAL AGENCY 1 DISTRICT 6.STATE AGENCY 413. <br /> [13.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME ata PHONE 415. <br /> Pacific Bell 877-8234161 <br /> 416.MAILING OR STREET ADDRESS <br /> 2600 Camino Ramon,Rm.3E000K <br /> CITY 417. STATE aZ <br /> e. IP CODE 409. <br /> San Ramon CA 194583 <br /> TANK OWNER TYPE OLCORPORATION 02.INDIVIDUAL ❑4.LOCAL AGENCYIDISTRICT Lj 6.STATE AGENCY am. <br /> [13.PARTNERSHIP C3 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> ' IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY H 44 0 3 ] 9 1 4 Call 916 322-9669 if uestions arise at. <br /> V.PETROLEUM USC FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®I.SELF-INSURED [2 4.SURETY BOND 07.SPACE FUND ❑to.LOCAL GOVT MECHANLS.A <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FLND&CFD LETTER [399.OTHER: <br /> ❑3.INSURANCE ❑d EXEMPTION ❑9.STATE FUND At CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check me boa to imi cae wltirh address shoOld be usol for legal twti6emtoa ad mailing. <br /> Legal mmfiatiosn and mailings will he sent W the tank uwncr unless box I a 2 is cb%ked. ❑ L FACILITY 02. PROPERTY OWNER ❑3.TANK 0 WNER 413. <br /> VII.APPLICANT SIGNATURE <br /> certification:1 certify that the mfutmation provided herein is me aM accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DAIS 424- PHONE .25 <br /> 707-765-1660 <br /> ' NAME OF APPLICANT(print) 424. TITLE OF APPLICANT 427. <br /> Scott Tannehill Agent for Pacific Bell <br /> STATE UST FACILITY NUMBER(Ass„sr...w +V. 1998 UPGRADE CERTIFICATE NUMBER(Asecy ae Iy) <br /> t (See Data£lenient 1,above. <br /> ' UPCF Hwiwrc-*(1/99)-112 bttp:l/www.anil*cs.org Rev.OLitJ00 <br />