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i ) Local Id ------- 21 State Id ------ 3) City Code 4 ) SCetue <br /> Prov/Elect Code 23,2- 5) Prmt ------- - <br /> Owner Infos 7) Name <br /> G) Address -- �15- -- =- '11L�✓ _1� <br /> / ----- <br /> 9) City. St -- -- "-- -------- 10) "-�- 11 ) <br /> 12) Public Ag -- <br /> Fac Info: 13) Name -- �. g - ---- <br /> 14 ) Address 151 /�- <br /> 16) City , St <br /> - fJ -�---------- 17 ) `1=i 10) ----- <br /> 6'l91' M. ------------ <br /> 19) 9 wn ----- - -' ------ <br /> qQ <br /> <O 1 Mail -Addr --==-=------ _ - <br /> 21 ) City . St -------------------- 221 -- 23) ----- <br /> 24 ) Phone - ` 32— <br /> 25) Fac Type <br /> 03 26) -------------------- <br /> Contacts : 27) Day/Phone ---- 28) <br /> 29) Nite/Phone --------------'- <br /> --------- '0) - <br /> --------- <br /> l ) Ctnr No f -I is Ctnr No ---- 11 Ctnr No -- - <br /> 2) State Container No --- 2) State Container No --- 2) Stat. Container No --- <br /> 3) Container Type 31 Container Type -•- 3) Contaln.r Type -- <br /> 3) Product Stored 31 Product Stored -- 31 Product Stored -- <br /> 6) Capacity (gal ) 1[ o 6) Capacity (pall ----- 6) Capacity (pal ) ----- <br /> 71 Monitor►ng System -- 71 Monitoring System -- 71 Monitoring System -- <br /> 01 Container Status 01 01 Container Status -- 01 Container Status -- <br /> 11 Ctnr No 11 Ctnr No 11 Ctnr No ---- <br /> `21 State Container No --- 21 State Container No --- 2) State Container No --- <br /> 31 Container Type -- 31 Container Type -- 31 Container Type -- <br /> 5) Product Stered -- 51 Product Stored -- 51 Product Stored -- <br /> _ <br /> 61 Capacity (gait 61 Cit ( ll ----- 6) Capacity (gall <br /> ----- capacity (gall <br /> 71 Monitoring System 71 monitoring System 71 Monitoring System <br />