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1 <br /> 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 ❑ 7.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 404' FACILITY ID# 1 <br /> 4 (Agency Use Only) <br /> BUSINESS NAME(S.-.FACILITY NAME , DBA a,i„8 Bu i-,A,) <br /> AT&T Corp. UE231 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 110 W TURNER RD#J LODI <br /> FACILITY TYPE ❑ I.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 /> MAILING ADDRESS 428-3 <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 /> AT&T CorpC/O AT&T EH&S (214)464-5591 <br /> MAILING ADDRESS 416. <br /> 308 S. Akard Street, 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 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 14 14 19 16 1 O 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® l.FACILITY OWNER ❑ 4.TANK OPERATOR 421 <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 infor n provided herein is true,accurate,and in full compliance with legal reguirem�ts. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> 5/22/2012 (214)464.31il <br /> APPLICANT NAME(print) 426 APPLICANT TITLEA 427 <br /> Steven J Hall Manager, EH&S "r <br /> h <br /> UPCF UST-A Rev.(12/2007) <br />