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'�.,ounccs STATE OF CALIFORNIA he STATE WATER RESOURCES CONTROL BOARD v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .� , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT D 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR UNITED GAS 610DIiA GIT-T- ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAL) 440 W. CHARTER WAY LINCOLN CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE CA ✓ BOX Q CORPORATION [ INDIVIDUAL E::] PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST._ TYPE OF BUSINESS ® 1 GAS STATION F__] 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) IF 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE GILL, JODHA 209-833-6427 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Ii. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ODHA GILL MAILING OR STREET ADDRESS ✓ box to indicate ED INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY P-0. BOX 1136 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME �SST�ATEZIP CODE PHONE#WITH AREA CODE CY 95378 209-833-6427 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION JODHA GILL MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY P.O. BOX 1136 E�:]CORPORATION Q PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE TRACY lA c1��-� CA 95378 209-833-6427 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND 8 STATE FUND b CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND s CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.a III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME RINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR J aTvV � Nil-t w LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It GC FT Iml 11015-161 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT'"ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR, H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRI STORAGE TANK REGULATIONS FORM A(6-95)