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NTINUED FROM THE FRONT <br /> _I C <br /> CC CODEC(ddPlr.h ard+f o(Onorlry/ :c o«w <br /> w.ItwsT (rylcl(y! — — <br /> rvellJr/ NA <br /> o. IoowTw <br /> C.TwtRO <br /> rNl�/Y/ (rPecl/Yl <br /> 7 <br /> IIL OPERATOR INFORMATION 1•tM 71 I n.tw 1.. <br /> A.MAM[ it.Vlll-A•IRI <br /> �.NI.Mt <br /> X X O N C O M P A N Y U S A W YES O NO <br /> M <br /> Q,",mv(Sm.lode a wA) <br /> • C.STATUS OF OI[w ATO'(Ewtl1 the SPPfOP•tea CeRtI htr0 She eIw•WT aOr;d/"DMeI.�lllfY'.) <br /> • - U L (other then feal.[t Ol rnn/ M (4'edh/ A 1 3 6 5 6 7 7 5 5 <br /> i-STATE O-OTHER paec(ry) .. . t• •. - « <br /> p-PRIVATE « <br /> [.ar'ccT on P.O.sow <br /> 2STREET R00 <br /> 3 1 1 2 3 <br /> 00 SM-1 T11 <br /> .... <br /> I.stet ow Town c.arwT H.ZII coos IX.INOIAp LAND - - <br /> It tM 1•ciliee Iontld on Ind.•n I.Oda7 <br /> X 7 7002 AYES in No <br /> 3 H 0 u S T 0 N •a <br /> L EXISTING ENVIRONMENTAL PERMITS <br /> A.wIo[S e1 (Aft tTWiON fom Proposd So. c1) <br /> (Dlrch•Klr to permit in progress. <br /> N A 9 P N A <br /> I N <br /> (.OT«[R(mellfYl <br /> •.U IC(Undlydround!n/ecnon of F+Rtar1 (rP•rrfy) <br /> c <br /> C <br /> 3 U N A 9. .. .. . <br />• •• ' «c. (NuadaRr Wirer/ [,oTH[w (spedfyl <br /> wcwA A. <br /> e f . (rpeciyJl <br /> G <br /> 9 R N A 9 <br /> XL MAP ' <br /> Attach to this application a topographic map of the ata[extending to at least one mile beyond pro b a OKh of tu ha_:d��e <br /> (nuke and discharge the outline of the facility.disposal <br /> the location of sadl of its awhere and proposed sivect and other Surface <br /> treatment, storage, a disposal facilities, and each well where k injects fluids undergrour14 (ttclude all sprllyr. <br /> water bodies in the map area.See inttructiOm for precise requirements. <br /> XIL NATURE OF OUSINESfrW"'— <br /> Former <br /> "'—Former gas station, currently an unimproved vacant lot. <br /> XIIL CERTIFICATION(erelnruvedcntlfthedinthis appllcarion and a(I <br /> /eertlfy under penahy of law that I h&w personally examined and am familiar wcv bk for Inloo talnng tM submiU&I Sul utlon conceined in Ih+ <br /> artachments and diet, based on my 1nquky of those persons Jmmediately rusponsl Nf�psrlahies far submhting <br /> application, I believe that the lnfomletlon h trim, accurata and complete. I am aware that [hers ane sign <br /> false information,)nduding the possibility of fine and lmprl"Onawst Sur[•• « <br /> (rye P;A eS.••6wATV Sues <br /> A, A«C A OII.NQAL TtT (Lii-,e ! 'I ^ � � (� <br /> R. T. Harvin <br /> RealEstate F, Engineering Manager K <br /> OOMMENTC FOR OFFICIAL UCE ONLY <br /> "A Form 75161 (R.f_70-001 Rwn,w <br />