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Alk Aft J'Ro <br /> MWJNIFIED PROGRAM CONSOLIDATED FGWR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS E: - FACILITY <br /> (One page per site) Page I_of I <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ®4.AMENDED PERMIT(Specify change) Tank Size-8K to 10K ❑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 <br /> I. <br /> Pacific Bell Telephone Company dba AT&T California I <br /> ID{i <br /> NEAREST CROSS STREET 401, FACILITY OWNER TYPE �LOCALGENCY/DISTRICT* 402. <br /> El Prortal Avenue ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS El 1.GAS STATION 0 3.FARM 0 5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ®6.OTHER [13.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 /> 1 <br /> [:]Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> Pacific Bell Telephone Company dba AT&T California GeoLoc:UE058) 214464-1929 <br /> MAILING OR STREET ADDRESS 409. <br /> 2600 Camino Ramon,Room 3E000 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 0 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT Ll 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 Telephone Company dba AT&T California (GeoLoc:UE058) 214464-1929 <br /> MAILING OR STREET ADDRESS 416. <br /> 2600 Camino Ramon,Room 3E000 <br /> CITY 417. STATE 418. ZIP CODE Ore. <br /> San Ramon i CA 94583 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 3 1 1 1 9 1 1 1 4 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <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 [16.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 mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ I.FACILITY [12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> IGNATURE OF APPLICANT DATE 424. 1 PHONE 425. <br /> I 05-15-07 214-464-3131 <br /> E OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Ja on D.Weller Manager,EH&S <br /> rSTATE UST FACILITY NUMBER(Agency use only) 429. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />