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1 D Number STAYE USE ONLY <br />\wllKallon b rerttrlM b! Feawal Y. fs as tn4ryrrwrN ante rh.r Aare bee <br />ufed ro Wore rfgulalW wMUneea abet Jatstrn' 1, NTi. tlrr an In the frarN u of <br />.Mar A 19ta, or Ilrar err breughr baotraMr Nal a. 19aa. T)sekda.rwarlewregr.arA <br />b rpuirW bT Seetbn 9003 0l rM Rewate Careerratfw aM Retoren Aet,1 RCRA k <br />u amended. <br />Tlr~ ;snman purpose d Ihr+notifieatron program i. to kxale and rsaluate undn- <br />ground onk+ Thar .Inrc ur lose .lured pttrokum w harardw• wb+nnm. 11 i. <br />esp[ard Thal the mlormaunn sou pros de .ill be based un reawruby asal4hk <br />rccurtl+. w. in Ihr abKnce n(sucfl record.. sour loco ledge. bets!. w reeolkttlnn <br />N'rw Naar \dlls! tiettlon 900? of RCRA. a+ amrnded, rcyulrh Ihal. ants. <br />eremprcd, nr mr. nl undergrnun0 unl+rhat •rurc reau4lA .ub•u ncn mua nwih <br />deslgnmed time ur IsKal ayencxa nl the elialente of Ihtir nn1+. Ossna m[an+- <br />lal in the or• 01 an uMerground +rnnge lank m u+t on \'usemh[r x. IVOa. w <br />bmugnr mro u+r afar thee dart am person r ho arm an urgergrnund .conga t}nk <br />utd Inr Illy stooge. u.e. o! dr+pen+ing of rcgulared +uD.slanm. and <br />l bl In rha• nK of an! underground stooge tank in u+e belorc \osember a. 19xa. <br />bur no Inng[r In uK on Ihal dal[, an) rxMn r he O+~ Wed weh Nnk Im1r1[d Yllel\ t%IOrc <br />Ili[ dncanhnwtion of m use. <br />Nha1 Lnka An Inelulea! CrdergrouM +IOnge tank r+ de(inN a• am one ur <br />:ombinallon of unk. That I 111+ wed to canuin an attumulatl(M N'rcguhte0 +ub- <br />+larlteti.-YW 1?I .hose .dome )including eonnmN urderground piping) n IOri w <br />moo: hcntath the ground. Swls eumpln arc underground ants+twing: I. paobrc. <br />u.edal. or dkscl (url, and L induarrul wheats, pe+licide.. herbicde: w fumipnu. <br />tYhar Lnka An Eaekdads Tank. rmosrd (ram the ground arc nq wblean to <br />mxdlraoon. phn 4nk+eMlu0ed from ndifinrion arc: <br />I.Iarm nr rc+ldentul lank+d I.IOOplbmor h+opuiry used for storing motorluel <br />for nnncommercul purposes: <br />L nnl+used fw storing Mang oil Iw rnnsumptise use on the prcmi:e+r hrrc storN: <br />)..KlnKlankl: <br />w plp[lia laahtr. UndWmg pthrnng Ara 1 r<gulutad under Ihr \nuul (,~. <br />Pipeline S.Im Act W 19h9. sx tha• Hanrduus Llyual Plps•hne Sutrls Oct nt 14-Y ,.r <br />Y hKh r an imnvate pgsehm txdip rcgular[d under Sues• Wr <br />7..unxe imprwndrtrml+. pII.. pond+. Ix lag,x.n+. <br />i. •wrm rater w ra+K +mer culketuM y•tcm+: <br />7. ^nr ~thruugh prom tool+. <br />1. byud tnp+w awKiartd plhenng brle+dmeth rrland w ul or tas pnducw.n unJ <br />plhenng Isp[riliwl+: <br />•• +tnngt ants .reared in an urdergrnund area huh a• ~ ha•<ms•nL x9ar <br />minty nrling. drill. shYlt. w IYnIK111I Ihf 411rar<lilnl I..Ilwla'd ury,n „r uhrs, Ili. <br />wnaee a the Ilex. <br />\ <br />Nhal Stdaunns An ("ererel! Th[ nMII K,IIIIM rcyuu: m[nn .pots w und[r <br />pouts yoraae unk+Ihat annum rcrylartd wbstarKe+. 7 hn induJ[• um sun•I,r nrr <br />de(ned an luranlow m sorrrun 101 Ilal al the Cumprch: n•„c fn, u.•nm. coal <br />Re.pons<. Cnmpen+anon ^nd Lubiln\Ate nr 1Yk01CE RCI ~\1.. rah lli[[.upuon,a <br />Ihov wbsurn~ replaced as hanNnus ra+tr order tiuhul[ (,n R(R ~1 hula, <br />rncludn pevokum, eg.. crld< nil w am IrMMn !h<reol w hKh I. Ayala +1 smna.rJ <br />eondiunn+ u' rcaysnwr+and pts.u•e rM d[gri ~ fuhrcnh[n .nJ IJ ' puunJ• xr <br />VIYYrc IrKh Yb~0lYlt 1. <br />N'Mrt To \Wifr! CompMA nwdolMn hImm shawkl h~ vm In Ihr +ddr~.. <br />.glsen aI the tap s><ihi+ frge. <br />When To VOtI(y! LOr Wen dund<rpouW stooge lanlsm u~or that has[Rt~n <br />oleo ouI N optmwn after Janwn 1, 19;J. bw wn m the ground. mua n,nas n. <br />Nos a. 191M J.tA Wen rho bring underground sron~n; nn41lu,• u.[ aver Nu. t, <br />19x.. must nail! rithin bda!+of Mngirlg the tools inru use. <br />P'wtaabt Aq saw rrbe krrorrbglT hi a elates w aubniu fats information <br />rh.a 4 M • tddl Mr ear 4 ntxea f1~,00a far each tank la rhkh <br />MIifIH~ ~n01 glrfll W IOr ~AILI1 !alit I11(omlaNOn Ya WEmlrlfd. <br />Plraseq~peorprintininkallitemse!ecepf'+igruturc'inSeetionV.ThistarmmuYb9eampksedfar Irdiwfenumberuf <br />er+dlloationeonuinln~undertroundaon{canto.lfmorcthan3unkaarcow~nedafthislootion, eonfintnfion.htet+ <br />photocopy the re\erx side. and supk continuation sheets to this form. atuched <br />a •. . a <br />]woe/ NSTe (CArtapralron. Individual, puDlie Apaney. or Other EntltYl (If fame as Section t, mark box here ^ 1 <br /> Facility Name Or Company Site ItlentifNr. ai applicable <br />itreet Addreu <br />:Atdtly $t/Ml AOOraa M Sbb Rwd. ai appliubb <br />miry Sub ZIP Code County <br />4rea Cods Phone Number City (nearest) Sbro ZIP Code <br />ryDSOfOwner (Markaafhafapplymf. ~- <br />^ Current ~ $bb a fatal Govt ~ a Prigb or <br />COrpWab <br />^ Former ~ Ftlderal pout ~ Dwrltrsflip Indicab Mark bdx Mro if bnk(S) <br />number of ~ era louledMbntl wnhtn ^ <br />bnka at this an Indian reaervatron or <br />(GSA ffCilfry I.D. Ia. uncarbin <br />1 bGtidn On other Indian trust lands <br />Nano (lf Same as Section 1, mark box Mee V) JoD Tilk <br />Area Code Phone Number <br />Mont box here only if dtif is an amarW W or ft/baaqusnt notilltalion for this IOt;ation. <br />I certify under penalty of law that 1 have personally examined and am familiar with tM information wbmitted in this and all attached <br />documents, and that based On my inquiry o1 those individuals immetliately responsible for obtaining the inlortnation, t believe that the <br />submitted information is true, accurate, and complete. <br />Name and official title of ovmar or ownai s authorized ropreaontativa ~ Sgnatun ~ Oats Signed <br />