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var% @ V v� VAV## %dJ14% WNI GPt HCSUUP{l.GJ 1..V1YITI* UAAnu UNDERGROUND STORAGE TANK PROGRAM »o I SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -: Z IO mCOMPLETE THIS FORM FOR EACH FACILITY/SITE `+o�a��♦ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5•CHANGEOFINFORMATION ❑ 7 PERMA NTLYCLOSEDSITE F'+ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 IV I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CT1 FACILITY LSRE NAME CARE OF ADDRESS INFORMATION .-S. ' FSG G ADDRESS ♦ NEAREST CLISTREETV ✓BBBh** ❑ PNM MW ❑ SIATEAGBAY ❑ WIPGRATO D LOCAL44DO ❑ RGBVIAGWGY ❑ PD&'1GUAL ❑ CIXKY AGENCY CITY NAME STATE SIT5PHONE M,WITHAREACODE S G CQ�-Dyt� ID CAq6oiaL.�Ik\RA 74TYPE OF BUSINESS: ❑2DISRdBUTOfl ❑ RIOGfSSOR ✓80x it INDIAN EPA IDM 1 GAS STATION ❑3 FARM +OTHER RTRUS'fLANDS« ❑ ATTHISSITE L/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE Al WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iMicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to inNkale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY �� C�OOU�NTTYY�/# JURISDICTION A AGENCY N FACILITY ID M #o1 TANKS at SITE CURRENT LOCAL AGE CY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE G / � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE LCHECK# CODE CENSUS TMCf�J�/(`) BUPERY180R-0ISTRICT CODE BUSINESS PUN FILED DATE FI EO 6�y ♦ O "' p� YES NO �l 3�6 6 / PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2 A8) \ DATA PROCESSING COPY \.ILII ,-