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<br /> INSMUCHONS X)R C'0MPI,FI1NC*RM'A'
<br /> L Care 1'O "A"sh ab be,completed mpleted fs r all N14V I'ltRWI'S,PERM 1'(I1 Ngf VS or an
<br /> 2. sumurr ONLY ONE,(")FORM W fca:a a I s.aty/ ire regardless of the number of lals , i cared at, the..r
<br /> ;I_ `:Ibis Rom shoal.(iae, i"onipletc l by either the, 1fXAL AChfWC;II3a��� �:.ga.'.� �. �.� <,.•
<br /> B, ]'Skase rype or print cle«rly all requested information.
<br /> I We a hard point WWI,arastrma"t,you are; making 3 copses.
<br /> °ISP OF M,- WARK ONLY olir,I`FENF
<br /> 1. Mark an (X) in the trox.meat to the hear that best describes the reason the ,oars is being completed,
<br /> Ir (11XIMISI'1 I INir(RMA IO fir..t DURI SS(AUSIP;a';`',WlSM101'I0
<br /> s, Record name aaael; dre,ss(Iritys'Nal kscation).of.the underground tanks,,
<br /> NUITe Address `>IIU'51'Have a valid Iahlical lcrceation including city,s:a; .t .€,t..rs. cott..
<br /> PD,W)X NUMBER ARE N(TI'ACC1.TrABI1!.
<br /> Include nearcm crelss street and nasrre of the o eratclr.
<br /> 2, shone number mum hame an area axle. H the night number is the smarty.. wr;8c "..,Alts," in prope,
<br /> 3. Check the ah ro a°l h five fcsr YPH 07,l3US NU,,,StS("RiNFAIayblat' �e°F "..,_.I t I ��..F ,. , t.,l�I €. .�yl, sic")
<br /> I Check the appropriate tresr for'1 PE Oh 131)`IN SS.
<br /> 5. If Facilityh=W is located can land wilhis.an Wast reser, ,kin sa aim Wan tnal faces,r a.ck the box ._a,_..,. QW,
<br /> (z, indicate the. "lUNH313,P €>f°Ira KS all ,lair;1SI.1'Ia,
<br /> . Record he I°.,I'A, II:t # ca-write in 9 . ..,..,.. ,gr vide l_
<br /> 11e PIit:ii'FR' S'OWNER 1IRTiChlZMATION c, Al t ss .,'a lai. t,a fl tm I is,t t I I"I
<br /> I. (kniphs all hems AMA smilm, w5v HA SI,(TtO €;.at the tai. write
<br /> .
<br /> 5 A
<br /> ON;Af.P�t.�pE C.;t^,�3. Be sure ti "l�% ., Ia��,e,x e;;'T _ _�t�:'r ka& t a U {is:..
<br /> L vr, plem au Rem tlhi,sr_,V . un,! S al" .t,r s avwr the e rte, in `9?f vii I£' lq If the won;writ ME AS AW
<br /> anoss Ink scanW, s e start,, ...,r I: .�,,%N
<br /> I I?C;hal.l.a( a Irt u(Ii.lall"I" ITSx` t t .rt, .l Ia1�s:,.es .(. ., littf r €Paa.a ,_ tIII-(Ia"t a;tri :I
<br /> Enter, r lAnd of Equalividon JAM F 1 NT stat tic &a g.. .�.'n nvnmea which 4 requVed ink e I or p;nnsl arpticafkall gall
<br /> sc pr sse t, Regnar'n n Mon theIRA? s; e ,.,e. Tat fir,,, mall rc _ e
<br /> (6 ,.,11 ) per a .>n me due on he numberA ,eaHons pine .a. ,','I's_ `l 1. tt E B Com Perimn ve I„�, g the
<br /> =ss` k r
<br /> Io?`t.-e i,..e„o:i`.,f,t,c"t-.Will 101 10 nqL if 011 ,t; MX WC ,. ..j,I•. 9UMOr Will ihar M h.,Cw xi Vu hCOPAWTIs
<br /> re,,,,�.o-dimg the 1xs,, or c=iWon, Idwan ipe AT at 91., .. r _.. wHw w On BCW_zt lbe F.��l s ing Adive BAN N '
<br /> Al"N"D 311.m.,€1`tku 11%02
<br /> i. ,:heck ONE 12 L-,q the _,t.... s thea KH he used for W11 I Ft„A1.AAR)B113ANG!%'Crill WWOONS,
<br /> SIGHS APH)UNIT IT'I t1,l 3 ,,t.=l Iia tyI( I I°I .
<br /> 1NSttttIl,CTI0SgtUR,'TD:F'LOCAL
<br /> a an, I r r„t„air_..nc ,, a <,pecdclemWed and con be olatained by calling the State Board, (910)739-2421, try
<br /> f„<;E".[y,a"Mt>T may be .a.igneo by Mc hyal SVUY hmaxvc,,to 6 aaunatser must be n astae k-ai,and cannot containn, al h e€. If
<br /> the Wal agency pref,at,the St, e I?r,u,;;i € . eekj Me Acwt} n;r duet, P teat:;e leirve it`blan€c”
<br /> rr IS'I I IIA RINIS INRISII ZI Y 014-1713F,I. C-, I,6 Gl.,ira`(,y,nj,,vr I ui�,,(_,7179 TI IL F C ILIf I "I )VERIFY 131
<br /> d1Lt:.CIas CTC 3:3I3`I1IIA ISm .::ak(. I1C "slits, ,tsslzi(°€m11c3 ( iNN(TI`BE PROCF-SSED H TI;BOB AUXMNPql`
<br /> sI..SIC.IIit I I Ct`I I'Il I,t I I"ao.
<br /> '11111 laai(: I.,'GPIN Y IS III°,%P 1 SIYII,I`s I )R IIHI(X)MFIAiIRC? 01?°t1IH'I,(I(SIN
<br /> t1(Ita>:ttyY U SJW.ONL'Y' IN1K)t3f tc'IT0N BOXANT) 1WR t'(aIC aSRDING ONE Ir(RM WAND A&S CIXI`D FOR—
<br /> "W s) to '11II,I U t'? ,"t (%=CI3 amtlrrs;,ie
<br /> 1;f€"I1 d OF CQUAYMA LA
<br /> S'I'AM I r .`t1.UR R!I''X) €St -�Sx 1,'0YROL 13OARD
<br /> two SwUnEs
<br /> DATA
<br /> P.O.DISK 3'21'
<br />
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