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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ T PERMANENT FACILITY CLOSURE 400 <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 FACILITY ID# _ 1. <br /> 1 404 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DDA-Doing Eluciness As) 3_ <br /> AT&T Corp. CAK482 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> J110 W TURNER RD LODI <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM El 4.PROCESSOR E 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40s. <br /> AT&T Corp. 214 464-5591 <br /> MAILING ADDRESS 409 <br /> 2600 Camino Ramon— Room 3E000 <br /> CITY 410. STATE 411. ZIP CODE 412 <br /> San Ramon I CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2 <br /> AT&T Corp. (214)464-5591 <br /> MAILING ADDRESS 428-3 <br /> 2600 Camino Ramon—Room 3E000 <br /> CITY 4284 STATE 428.5 ZIP CODE 428-6 <br /> San Ramon CA 1 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> AT&T Corp. (214)464-5591 <br /> MAILING ADDRESS 416 <br /> 2600 Camino Ramon—Room 3E000 <br /> CITY 412 1 STATE 418 ZIPCODE 419 <br /> San Ramon CA 94583 <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 Q 13 1 1 19 1 1 1 4 1 Call the.State Board ot'Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® i.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 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 cerfifj that th-cluformationprovided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 427- <br /> 6/11/2008 <br /> 25.6/11/2008 214 464-3131 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Steven J. Hall Manager, EH&S <br /> U PCF UST-A (1212007) <br />