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U E058 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility)E: <br /> TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404FACILITY ID# <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA Doing Business As) 3. <br /> Pacific Bell Telephone Company dba AT&T California UE058 <br /> BUSINESS SITE ADDRESS 103' CITY °4. <br /> 10 E 12TH ST TRACY <br /> FACILITY TYPE ❑ 1.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. STATE 411. 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 /> az8-3 <br /> MAILING ADDRESS <br /> 2600 Camino Ramon- Room 3E000 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> San Ramon ICA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Pacific Bell Telephone Company dba AT&T California (214) 464-5591 <br /> aib. <br /> MAILING ADDRESS <br /> 308 S Akard St-Room 1700 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Dallas TX 75202 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <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 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> azs <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR <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 informa ' n provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> 7/5/2012 214 464-3131 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Steven J Hall Manager, EH&S <br /> UPCF UST-A <br /> Rev.(12/2007) <br />