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r <br /> . Ali r. % .- ••^•�.. na-sv VnA.cJ A.vn1�tIUAHO <br /> ORM A. UNDERGROUND STORAGE TANK PROGRAM _R <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> -- -. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .^y <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAI -RMIT S OWIGE OF INFORMATON <br /> ONE ITEM ® ❑2 INTERIM PERDNf ❑A AMENDED PERMIT ❑ T PERMANENTLY CLOSEp SRE <br /> E]B TEuvoRua SITE aos,rE <br /> I.FACILITY/SITE INFORMATION R ADDRESS—(MUST BE COMPLETED) 3 <br /> Ic <br /> F /SITE <br /> SIRF OF ADDRESS[KORMATKW <br /> ADDRESS <br /> _ FiE ST <br /> CROSS STREETb"Idyl ❑ PAI R" ❑ SIAR44EKT <br /> ❑ m•mnow ❑ +mp PAL460 � <br /> CITY NAME ' ❑ l0ftK ❑ mAArATgKY 4:1.. <br /> VMEETSTATE <br /> N <br /> Z' PHONE..NITXAREACODE .APOIlF ZDISTRBUIORLPFCCESSOR ✓(fa I INDIAN EPA KI A <br /> ❑J FARA Ej 5 OTHER R� a LANDS ❑ 131 WTANK'.AT THIS SfTE <br /> ONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> KLST) PHONE•N TX ARFA CODE NAME MST.F RST) PHONE WITH� AREA CODENrAff ,FIRST) <br /> PHONE,WRH AREA CODE <br /> RIMAE MAST.FYLST) PHONE F WITH AREA CODE <br /> /6 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> WtV I <br /> / / v ADDRESS INFORMADON <br /> IX STREET ADORES$ ✓Bo.bitlrtre ❑ PARTNERSHIP <br /> ODRPOTK)N 11CY LOCAL-AGEN ❑ ST <br /> MFEDERAL-AGENCY <br /> AME ❑ KdVIDUAE ❑ COIRRY-AGENCY <br /> /9 S ZIP CODE PH .WITH AREA CODE <br /> I zy <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> Z/ ADDRESS INFORMATION - <br /> I+STREET AOORESS ✓BaI b:ur�le <br /> ❑ CORPORATION ❑ PARTN ❑ BTATE-AGENCY <br /> ❑ LOUNAGENCY ❑ .AGENCY <br /> CITY NAME ❑ IIADIVIDIIAL 11COUNTY-AGENCY <br /> Z STAT ZIP WITH AREA CODE <br /> IV. ,6EGALNOTIFICATION AND BILLING ADDRESS <br /> PY>...:ECK ONE RTI BOA INDICATING WHICH ABOV[ADOR[SS SHOULD BE USED FOR BOTH LEGAL MOTEICATTON ANO BILUNG, L ❑ ❑ <br /> IL uL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED A SIGNATIATE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> OUNTY[ JURISDICTION[ AGENCY A / <br /> tE <br /> FACILITY iD[ � Jto/TANKS d SITE <br /> C� <br /> LOCAL AO[HCY FACILITY 101 <br /> D BY NAM[ <br /> PHONE/WITH AREA COD! <br /> MIT NUMBER <br /> APPNOVAL DATE PEB IT!%M TL <br /> 9Z <br /> COD[ N TMCTP VMOK-0I[T111CT COO! BUBRN[[[PLAN FK[D <br /> PN.CO <br /> CHECK F OMIT AMOUNT U CNMO[AYOUIIT F[[COD[ YES NO L// 5 ("!/,. <br /> � K[cerTP BY. Jb <br /> THIS FARM MUST CE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATKNI(n INNESS THO O A CHANGE OF SITE INFORMATION ONLY. <br />