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LIWED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROLT" STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> aoo. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ®8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY F 1 <br /> Pacific Bell Facility <br /> ID# <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402 <br /> North Church Street ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM ®5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division,section or 406• <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 1 ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 408. <br /> Pacific Bell 925-823-6161 <br /> MAILING OR STREET ADDRESS ' <br /> 2600 Camino Ramon,Room 3E000T <br /> CITY 410. [CA <br /> ATE 411• ZIP CODE 412• <br /> San Ramon 94583 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Pacific Bell <br /> 925-823-6161 <br /> 416. <br /> MAILING OR STREET ADDRESS <br /> 2600 Camino Ramon,Room 3E000T <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL [j4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo. <br /> 3.PARTNERSHIP 0 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- 0 3 1 9 1 4 Call 916 322-9669 if uestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and trailing. 421 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked [1 1.FACILITY El 2. PROPERTY OWNER ®3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT F APPLICANT DATE 424. PHONE 4zs. <br /> 7/13/01 707-765-1660 <br /> NAME APPLICANT(print) 426• TITLE OF APPLICANT az1. <br /> Stig Werehus Agent For Pacific Bell <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> a28. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />