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Phase print or type with EIyTE type(12 eh,•3eters per inch) in the unshaded areas only GSA na 02Aa-EPA4T <br /> ( W9 K 1DNumba ter from a 1 " <br /> -EPA 4D:Number Etrter from s. ` r�rY �n P 94,)'' <br /> Cr A D <br /> XV.Map <br /> -tssAttach to this application a topographic map,or other equivalent map,of the area extending to at least one mile beyond property !• <br /> >.A boundaries. The map must show Me outline of the facility,the location of each of its existing and proposed Intake and discharge <br /> structures,each of its hazardous waste heetmen4 atorage,or disposal fadlites,and each well where it Infects tulds underground. <br /> ^ti Include all springs,rivers and other surface water bodies In this map area See Instructions for precise requirements. £ <br /> .:DCVI:Fadilty DralNtig, <br /> All=`ng facilites must Include a scale drawing of the fadllty(sea Instructions for mon detala <br /> c` . .. ..... .. _, .. .. - _ _. _...._... . ... ..... . . 0--+c:. <br /> _,XVII:Ptiofognptis;;;�-- <br /> AI!existing faelilflu must include photographs(serial orgrounddevel)tut dearly dellneats all existing structures,ax/stng storage, <br /> treatrthent and dispose/arose;and sites of future storage,treatment or disposal areas(ace instructions for more debdl). <br /> XVII(CeFdfication(b) r-; <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br /> accordance with a system designed to assure that qualified personnel properly gathersnd evaluate the information submitted. <br /> Based on my Inquiry of the person or persons who manage the system,or those persons directly responsible for gathering <br /> the Information,the Information submitted Is,to the best of my kno wledge and belief,true,accurate,and complete. I am a ware <br /> that there aro significant penalties for submitting false Information, Including the possibility of fine and Imprisonment for <br /> knowing violations. <br /> Ownx Signature Doe Signed <br /> Name and Official Trtb(Type or print) <br /> Omer Signature Date Signed <br /> Name and Oficial 799(Type or print) <br /> Operator Signature Doe Signed <br /> Name and Officio Tab(Type or print) <br /> Operator Signature Date Signed <br /> Name and Official Title(type or print) - <br /> '.XIX:C011111fetlla�_ <br /> Note: Mail completed Iomr to Ms appropdete EPA Regional or Stats Office.(Rafal rat/nsfruetona for more <br /> EPA Form 8700-23(Rev.11-30-93) Previous edition Is obsolete. -7 of 7- <br />