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UNIFIED PROGRAM CONSOLEDA,TID FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per%cility) <br /> TYF$OFACTION ❑ 1.NSW PFJtI1f r ® S.CHAMM OF INFORMATION ❑ 7.PERMANENT FACILITY C1 OSURfi 4K <br /> l OOs 9�1 Q 3.RENEWAL PBlthfl'r ❑ 6.TBMPORARY FAC WY CI MURE ❑9.TRANSFER PERMIT <br /> L FACIIdTY INFORMATION <br /> TONV&NUMMMOPUSTS AT FACILITY 4x FACILITY ID I 1. <br /> 1 uu <br /> BUSINESS NAME(at...r cuffmAmctm►-aora,taew"A* <br /> PsCMc Beit Tolmhone Company dba AT&T Califomia UE042 <br /> BUSW$UNMADDRBSS lax CffY too. <br /> 345 N.SAN JOAQWN ST. STOCKTON <br /> FAMMYTYPE ❑ 1.hVTOR VEHICLE FU&W0 ❑ 2 FUEL DISTR1 =MON 40' Is JIM facility boated on indica ltraa tion or � <br /> 13 3.FARM 4.PROCRUOR 6.OTM Tfmt 1�dsT ❑Yes ®No <br /> IL PROPERTY OWNER EMRMATION <br /> FROPBRTYOWNERNAMB PHONE 4oe <br /> >Padfic Bel Telephone Company dba AT&T California1 (2141464-5591 <br /> bMAnXRO ADDRESS <br /> 2600 Camino Ramon—Room 3E000 <br /> CITY Ora S'rATM3 ZIP CODE {ra <br /> San Ramon ICA 94583 <br /> IIL TANK OPERATOR EWORMATION <br /> TANK OPERATOR NAME 4ms-f I PHONE aua <br /> Padfic Beit Telephorke CompMy dba AT&T Califomia (214)484-5591 <br /> M1 JUM ADDRM 42W <br /> 2600 Camino Ramon-»Room 3E000 <br /> CITY 084 STATE n+-s 1 ZIP CODE Ori a <br /> San Ramon ICA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TAWGWNBRNAN% 414. PHONE 41). <br /> Pacific Beit Telephone ComoU dbo AT&T Califomia (214)464-5591 <br /> MAS.NO ADDRESS 41& <br /> MS.Akard St Room 1700 <br /> 4n. STA'L'L 4u. ZIP CODS 419. <br /> DeRa6 Tx 75202 <br /> OWNimri . ❑4.LOCALAGENCYIDMSTR= ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ r.FEDERAL A0fa7dCY 19 &NON-GOVIIRNMENT <br /> V. BOARD Olt EQUALPLATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY H 1 0 13 11 19 11 1 4 1Call the�6e13oerd olFqualixation, cl las Division iFtherc e►c questionx � <br /> ,VL PERMIT HOLDER INFORMATION <br /> Imus pm*t and m d legd m"IcW is and mailiap to: ❑ 1.FACILLTY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER © 5.FACILITY OPERATOR <br /> SUMVWX OFDIV1810N,88CT'IOK OR OFFICE(Rupp ,d IV PW&Aomdo Only) <br /> VIL APP C SIGNATURE <br /> C11 TMCATION. [e2dw flaaat as b tru0,gaMt,6 sad in full com lianco with R1 reciodrementL <br /> AMACANT3KI'NATURE DATE 4u FftGNMI <br /> 1816f2009 214 464.3131 <br /> ni APPLICANrTITEE U1 <br /> Steven J. Mana er EH&S <br /> amlV ItMA ftimmm <br />