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Mail To: State Inspec t of Oila - Building 1, Ro~-5 page Z oi' 4 <br />1001 E. 62n Avenue - Denver, Colo. 80 6 <br />---==--=---=====--=--=-==O__===6====e==e===ee__=====_=_====_=_=_==__==__=__ <br />for state use only <br />State Identification <br />Date Received <br />Date Entered <br />.Data Eatry Comments <br />__~__________________~===-0===-______=-=========~~_==__===__=_=_=_=__=__=__ <br />Please type or print all items except "signature" in Section V. This form <br />must be completed for each location containing underground storage tanks. <br />If more than 8 tanks are owned at this location, photocopy page 3, and add <br />continuation sheets. NO. OF CONTINUATION SHEETS = <br />NOTIFICATION TYPE A. NEW FACILITY B. AMENDED C. CLOSURE X <br />-----------------------evvvevvveevveeeveevveeeeee=======_==__==______=----- <br />----------------------- ----- <br />I - OWNER (corparation,individual,public ageney,or other entity) <br />TRAPPER AfIP]IMG Ii1C <br />STREET ADDRESS COUNTY <br />P 0 BO!C 187 T!OFFA: <br />CITY ZIP CODE PHONE NO. <br />CRAIG CO S1G26 303/824-4401 <br />eeeeeeeeee_~=eevveeeveeves=evvveevveevvevvvavveee~=eseee_=ev.eeevoe==eevoee <br />II - FACILITY NAHE ~ COMPANY SITE IDENTIFIER, AS APPLICABLE <br />STREET ADDRESS OR STATE ROAD, AS APPLICABLE COU`1TY' <br />SAME <br />CITY ZIP CODE PHONE NO. <br />ee.neeeeoe===eeeeveeeeeveveveeve=v=evvvevvveveevvevveeveee=eeee=====_______ <br />III - owner type: COMMERCIAL PRIVATE X FEDERAL GOVT <br />STATE GOVT LOCAL GOVT UNCERTAIN <br />e..ee.ee.eeeeeeevee------v---v--svevveeaeesveaveeveeeveeve_=--e------_--_-- <br />IV - TANKS LOCATED ON INDIAN LANDS- OWNED BY TRIBE INDIVIDUAL 'f <br />====eoeoveoeeeeeeeeeeeeveeeeoeeexeeeveeseeveeeeeveeeveevv------------------ <br />-------------- <br />V - FACILITY TYPE gas station- petroleum distributor- industrial- <br />commercial_ contractor- trucking co._ railroad- utility co. , <br />auto dealer- airline/air taxi- aircraft owner- residential_ <br />farm- local government- state government- federal government, <br />federal military-, other Sl;.°.I'ACE COAL PfI:IE <br />e eoevevo.evvoee.eeeeeeeeevoeeeee3===eveeeeeeeeveeevee:ee~eevo===_====omecco <br />VI - CONTACT PERSON AT TANK LOCATION - TITLE - TELEPHONE > <br />.;ILLIA;! AG1;::I! f„^, i:;VI'0'f~i~?I.?.L ~[':GIiIEI:P. 30~/C?4 .':Cl <br />====e=ee-======peee=e=eveeeeeeeeeeee=ee=e==ev====Q_~___________________°__= <br />VII - FINANCIAL RESPONSIBILITY - I have met the financial responsibility <br />requirements of Subpart H, Part 280 of 40 CFR, using these Methods: <br />SELF INSURANCE ~ COMMERCIAL INSURANCE RISK RETENTION GROUP <br />GUARANTEE SURETY BOND LETTER OF CREDIT TRUST FUND <br />COLO.UST TRUST FUND OTHER <br />_______________________________=e=======e=====6==e==e=====__=__________==__ <br />~I~I - CERTIFICATION - Sign after completing all sections of form. --- <br />I certify under penalty of law that I have examined and am familiar with <br />the information submitted in this and attached documents, and based on my <br />inquiry of the individuals immediately responsible for obtaining <br />information, I believe the submitted information is true, accurate, and <br />complete. <br />YAMS AND OFFICIAL TITLE OT OWNEA OR AUTHORIZED REPRESENTATIVE . <br />signature <br />5/"'3/°0 <br />