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- tsp -cts <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® t NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> UNITED GAS O-DHA- G IL. <br /> ADDRESS NEAREST CRnSS STREET PARCEL#(OPTIONAL) <br /> 440 W. CHARTER WAY LINCOLN <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOCKTON CA <br /> ✓ BOX ]CORPORATION `7C INDIVIDUAL [:] PARTNERSHIP LOCAL-AGENCY ]COUNTY-AGENCY' ] STATE-AGENCY' ] FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> ' <br /> If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the US] <br /> TYPE OF BUSINESS ® t GAS STATION 0 2 DISTRIBUTOR ] ✓IF INDIAN 11OFTANKSATSITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> I] 3 FARM I] 4 PROCESSOR ] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> GILL, JODHA 209-83342_7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> JODHA GILL <br /> MAILING OR STREET ADDRESS ✓ box to indcale ] INDIVIDUAL ] LOCAL-AGENCY (] STATE-AGENCY <br /> P-0. BOX 1136 i]CORPORATION (] PARTNERSHIP = COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> TRACY CA 9537 209-833-6427 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> JODHA GILL <br /> MAILING OR STREET ADDRESS ✓ boxio indicateINDIVIDUAL <br /> ] ] LOCAL-AGENCY STATE-AGENCY <br /> P.0. BOX 1136 CORPORATION PARTNERSHIP I] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> TRACY 9A 71 CA 195378 209-833-6427 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate O t SELF-INSURED (] 2 GUARANTEE (] 3 INSURANCE (] 4 SURETY BOND (] 5 LETTER OF CREDIT I]6 EXEMPTION O 7 STATE FUND <br /> (]8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER ] 9 STATE FUND d CERTIFICATE OF DEPOSIT ] 10 LOCAL GOVT.MECHANISM (] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> F:TANK OWNER'S NAME RINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> ;THAis c i« Ct <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> IE FTTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT If -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6.95) <br />