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LI. 11ovull fa4 L,AJn I nL CIOAHO <br /> ORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ! FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .m <br /> MARK ONLY ❑ I NE NEW, <br /> PERMR ❑ 7 RENEWA. RMIT ❑ 5 C1�:OFNATIONJ PERMANENTLYCLOSEDONE ITEM INTERIM PENMR AMENOEOPEPoAIT ❑6 TEQO$UiE <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS — (MUST BE COMPLETED) I <br /> ---------------- <br /> IL <br /> F /SITE NAME <br /> y CSE OF ADDAESS MFORMATION <br /> ADDRESS <br /> I�Fj.REST GgSS STREET r\obi O lWtTw Oi ❑ nAtEAG[ry[y µ <br /> /`flp//� O wamml O Iax.mu IUE� 1� <br /> GTY NAME ❑ fOIQE! ❑ �ARTAGDO <br /> STATE <br /> t0 ^A /I- PHONE I.WITH AREA GJEIE <br /> OF ROSINESS a <br /> ❑ Z DISIiOMPOR 0 1 P{IOLESIDR ✓Bp 4*OAN EPA ORESEF <br /> I GAS SLAT" ❑7 FARM ❑5 DTIER TRUST �' <br /> 0 -0 I W TANICF �5/ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON( <br /> ( SECONDARY) <br /> D NAME LAST.FIRST) PHONE I WITH AREA <br /> S CODE NAME(IAST.FIRS ) PHONE 0 WITH AREA CODE <br /> N S NAME(LAST, <br /> 5SOE 4 WITH AREA CODE N_<4" NAME RAST,FNRST) PHONE•WRH AREA CODE <br /> i6 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> I Y' ADDRESS kIF ATION <br /> (23 <br /> M «STREET ADDRESS <br /> ✓Bub^a T ❑ PARTNERSMAT <br /> P O STE-AGENCY <br /> CORPOMTRJN ❑ LOCAL-AGENCF ❑ FEDERAL-AGENCY ' <br /> AME ❑ BAJrvDUAL ❑ COIMTY-AGENCY <br /> /� S Zlv CODE vH .WITH AREA CODE <br /> �2 zY <br /> III. TANK OWNER INFORMATION 6 ADDRESS, (MUST BE COMPLETED) <br /> Z7 UTEX ADCHESS INFORMATION <br /> «STREET ADDRESS <br /> �/- ✓BmbMCAb ❑ PARTNERSW ❑ STATE-AGENCY <br /> L{� ❑ CORPORATION ❑ LO('µ-AGENCY ❑ RAL-AGENCY <br /> GTY NAME ❑ II'IDIYIGIAL Cl 01 <br /> Z <br /> STATE ZIP PH WITH AREA CODE <br /> 2 32 <br /> IV. 6EGAL NOTIFICATION AND BILLING ADDRESS <br /> - - •-CK ONE(1)BOX INDICATING w'NECN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING; L <br /> ❑ IT. ❑ IIA❑ <br /> THIS FORM HAS BEEN COMPLETEO UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> APPLICANT$NAME(PRINTED 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> OUNTYY JURISOICTIONI AGENIC, ♦ L <br /> 5 FACILITY IDtof TANKS A131TE <br /> LocAl ADENcr PACN.m ID t <br /> APMOVEO by NAM[ PROM[/WITH AREA COD[ <br /> MRNUMBER ) <br /> APPNOV AL DATE P[BYIT[IM APON9AT[ <br /> 7� <br /> 3[ <br /> 'J�f <br /> CO" CN, tUtM*Ess tTBACTE VItOB-0ItT111DT CODE RAN lNED <br /> PNLD <br /> CNECKF YES NO Ely� ) <br /> AYR AY001FT CHABO(AYOUNT FlC CODE --No <br /> BPitY: <br /> THIS FORM MUST BE ACCOW ANTED BY AT LEAST(i)OR MORE TANK PERM(T FORM 'B'APpUCATpN(SL UNLESS THIS ISA CHANGE OF STTE INFORMATION ONLY. <br />