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gOD PROGRAM CONSOLIDATED F <br /> TANM a.33 l <br /> FACILITY <br /> UNDERGROUND STORAGE TANKS - FAC <br /> (One page per site) Page 1 of 1(new tank) <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE Imo.p D I VI <br /> 3 1 ? <br /> -Doing:Business ns ::FACILITY <br /> NAME Same as FACILITY NAME or DBA L <br /> .........................................................................................................................:.. <br /> BUSINESS ( ,ng ) 3. <br /> Pacific Bell iD# 1 <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> El Portal ®1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑1.GAS STATION ❑3.FARM ®5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP [17.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 /> One diesel tank ❑Yes ®No <br /> .;: ;.:;:;.;:::;..;<:.;<;,,,,:,,,.:;:.:;,:,::.::.:.;:<.::.:;;<:;:;<.::;:<.:.; ..:::......... <br /> ................. <br /> ...:............. <br /> :...: ::. <br /> PROPERTY OWNER NAME PHONE 408. <br /> Pacific Bell 877-823-9833 <br /> MAILING OR STREET ADDRESS 409. <br /> 2600 Camino Ramon,Rm. 3E000K <br /> CITY 410• STATE 411• ZIP CODE 412. <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 02.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> : ::::: : <br /> : ..:........... ':; ;:;; ; iii' is><i :J'� ::: : `O : ;' »� <br /> : . : :: .:: ::::::::::::::::::: ::::::::::::::::::::::::::::::: .. : ; ...........:..., ±: <br /> ,.....,............:.:.........,,... <br /> .. <br /> TANKOWNERNAME ala. PHONE ats. <br /> Pacific Bell 877-823-9833 <br /> MAILING OR STREET ADDRESS 416. <br /> 2600 Camino Ramon,Rm. 3E000K <br /> CITY 417. 1 STATE 4M 1 ZIP CODE 419. <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.��FEDERAL AGENCY <br /> .. <br /> ................................................... .............:::..:.::.:. . .:..:......:.......:....:...:....::::::::.:::.::.:..:..::.:.:.:::::::... ... <br /> TY )H 44- 0 1 3 1 1 1 97 T-4­1 Call(916)322-9669 if questions arise alt. <br /> N II.ITY. .... <br /> :. ..... �PETRLEI: TI`FfNA1T .. . .. ::<:::::::<:::::::>::; <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> '[[[ci fi ii ii:ii'i is ::.:.'is.. .. ......:.....:.:... ..::•:::ii::i:.:.... .. - :::ilii:::i>::::: :::;i.�.>:t...::: <br /> ::::.::::::>::.:::::::::::>:::::::;::.:............. ::::::::: : ::: ] GAZ.NO�CA�`IOC:.�.MA�L�T. .AD........................................:..........................................:.::.. <br /> ,:. :::.::. .. .....,,.:...... <br /> ..................... . .....:..,.......:.........:..............., ...:....::,.....,...,...:. <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> ... . i � � �.+�(�'�; (��+� <br /> ::::::::::::.:::::::.:::::::::::::::.>r::::.»::: <br /> : ::...... . : :' iii: :.::'< '':-::' ::: :.' :> ': T. .:A �%:r.F:#i :T:4i,[f:\T.' .........;:::.;:.:::>:::::.;:.::::.::.:::.;::.;:.::.;:.;:.;::.::.;::.:: <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424• PHONE 425. <br /> 707-765-1660 <br /> NAME OF APPLICANT(print) 426• TITLE OF APPLICANT 427• <br /> Scott Tannehill Agent for Pacific Bell <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />