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:� Cie s3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM 27"1S <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. v <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT 1�� <br /> I. FACILITY INFORMATION o D 3l,S'7 <br /> TOTAL NUMBER OF USTs AT FACILITY 4q FACILITY ID# 1' <br /> 1 (Agency Use Only) (� <br /> BUSINESS NAME(SamersFACILITY NAME orDBA—DoingBusiness As) s \� <br /> AT&T Corp. <br /> BUSINESS SITE ADDRESS 103, CITY 104 <br /> 90 W.Turner Road Lodi e <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 465. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHERTrust lands? ❑Yes ®No \/ir <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401. PHONE 40L <br /> AT&T Corp. 800 566-9347 (� <br /> MAILING ADDRESS 409 \� <br /> PO Box 5095 <br /> CITY Oto. 1 STATE 411. ZIP CODE 412 <br /> Dallas TX 75202 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 429-2 <br /> AT&T Corp. (800)566-9347 <br /> MAILING ADDRESS 429.3 <br /> PO Box 5095 <br /> CITY 4264 STATE 428-5 ZIP CODE 428.6 <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415• <br /> AT&T Corp, (800)566-9347 <br /> MAILING ADDRESS 416. <br /> 308 S.Akard,Rin 1700 <br /> CITY 417 1 STATE 419. 1 ZIP CODE 419, <br /> Dallas TX 75202 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT Q 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(TD HQ 44- 1 0 1 4 1 4 1 9 1 6 1 677 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to. ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> Q 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) ' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGN T RE DATE 424- 1 PHONE 425. <br /> �- 5/21/2015 (214)464-5553 <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 427 <br /> Kevin J.Tosh EH&S Manager <br /> UPCF UST-A Rev.(12!1007) <br />