COMPLIANCE INFO_2007-2012 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION—FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ I.NEW PERMIT ® 5.CHANGE.OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE. 400. (Check one item only) (� 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION 'TOTAL NUMBER OF USTs AT FACILITY 704FACILITY ID# _ t 1 (Agency Use Only) BUSINESS NAME(Same m FACILITY NAME or DBA--Domg Business As1 3 Pacific Bell Telephone Company dba AT&T California UE058 BUSINESS SITE ADDRESS 103 CITY 104 10 E. 12TH STREET TRACY FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405 ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes Z No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407, PHONE 408. Pacific Bell Telephone Company dba AT&T California1 (214)464-5591 MAILING ADDRESS 409. 2600 Camino Ramon—Room 3E000 CITY 410 STATE 411. 1 ZIP CODE 412. San Ramon ICA 94583 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428"2 Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 428.3 2600 Camino Ramon— Room 3E000 CITY 428.4 1 STATE 428-5 ZIP CODE 428.6 San Ramon CA 94583 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415, Pacific Bell Telephone Company dba AT&T California (214)464-5591 MAILING ADDRESS 416 2600 Camino Ramon— Room 3E000 CITY 417. S"TATE 418 ZIP CODE 419 San Ramon ICA 94583 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420 ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 0 13 1 1 19 1 1 1 4 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ® L FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3 TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 VII.APPLICANT SIGNATURE CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424 PHONE 425 6/3/2008 214 464-3131 APPLICANT NAME(print) 426 APPLICANT TITLE 427 Steven J. Hall Manager, EH&S U PC F UST-A (12/2007)