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UE042 <br /> UNIFIED PROGRAM CONSOLIDATED FORM =400 UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> TYPE OF ACTION ❑ I.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# I _ I I _ J-7I <br /> 1 (Agenc) Use Only) <br /> BUSINESS NAME(same as FACILITY NAME o,DBA—Doing Business As) 3 <br /> Pacific Bell Telephone Company dba AT&T California UE042 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 345 N. SAN JOAQUIN ST. STOCKTON <br /> FACILITY TYPE ❑ I MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4 PROCESSOR ® 6.OTHER Trust lands" ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> Pacific Bell Telephone Company dba AT&T California 214 464-5591 <br /> MAILING ADDRESS 409 <br /> 2600 Camino Ramon —Room 3E000 <br /> CITY 410 1 STATE 411 1 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> Pacific Bell Telephone Company dba AT&T California (214) 464-5591 <br /> MAILING ADDRESS 428-3 <br /> 2600 Camino Ramon —Room 3E000 <br /> CITY 428-4 STATE 42$-5 ZIP CODE 428-6 <br /> San Ramon ICA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala PHONE 415 <br /> Pacific Bell Telephone Company dba AT&T California (214) 464-5591 <br /> MAILING ADDRESS ale <br /> 308 S. Akard St. Room 1700 <br /> CITY 417 STATE 419 ZIP CODE 411) <br /> Dallas ITX 75202 <br /> OWNER TYPE: ❑ 4 LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6 STATE AGENCY 420 <br /> ❑ 7 FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 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 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to. ® L FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION-SECTION.OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE > DATE 424 <br /> _� PHONEzs 4 <br /> 9/20/13 (214)464-2847 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE a2i- <br /> Lynn Hunt Manager, EH&S <br /> PPCF UST-A Rev.(12/2007) <br />