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1N%-1'RUC'I1ON1S FOR()OM'T,L;E°C IG IN) 'TI'
<br /> GENERAL fN,'G'RU('I10NS.
<br /> L One I`ORN-1 "hl" shalt be completed for each tarok for till NEW PFIRMM,PERmn,0°Ed1'NGU a, IMOVAI,�and/or any
<br /> othcr'E,,,%Na INFORMN1101d CEEANG13
<br /> 1 This farm should be completed by either the Pi E".APE'E;EC:f1Nr or the:LOCAL SAGE N Y UNDEIERGROUNT)°FAN
<br /> INS E'E.zC't OR,
<br /> 1'&e° >s y,,r)e or print clearly all requested information.
<br /> 3iark vn N14 ttt � s° t t r Hna item that beet describes the reason the form is being corn lcteci %,"g'
<br /> 2, Indicatc tht I i? &rr Facility name:where the tank is installed,
<br /> 1. TANK T) A 1T)C)N-(X)MP1JTpE All,rl'FMS-TES UNKNOWN- ),SPFX IJ
<br /> A, Indicate owners tank ID -If there is to tank number that is used by the owner to identify the tank(ex.AB70789),
<br /> 11. Indicate tiro narne of the company that manufactured the tank(ex. FiCMF'TANK MFG,).
<br /> C. Indicate the year the tank was installed (ex. 1%7).
<br /> 17. Indicate the tank capacity in gtaltons(ex.25,W0 or 10,(0)etc.).
<br /> IL TANK(X)NIT'Nn'
<br /> A, I, if `lCtTOR Llf1C'L I"U1,11,check box I and complete items B & C";,
<br /> 2. If:not 1,d.t)'I'OR V1,111C LE,FUEL,check the appropriate box in section A and complete items B D.
<br /> 13, Check the appropriate box. �
<br /> C. Check the type of N!t#(),rO 4 EHICL L`L'E L(if box 1 is checker! in.A),
<br /> T a, Print be .t.,.nni caa name of the bazardknm.ulrst aa,Rc-tor eel at The tank and the C°,r).S. , (Cherrical abstract Service
<br /> HL LANK ...MARK ONE,Ia !'M ONLY IN BOX A,Es,C.&1)
<br /> C 1a<c o;iv a.F,c :re:rn Er. l z'kf., s SYS l -M,TA 4 K M .g Ir.Ifltlh„ I: I'I:TRIOR LINING acrd CORROSION 1'ROT2'C'11Ci
<br /> 2, If OTIff'14', Litre in the space p rovifled, ,
<br /> a
<br /> IV, PIPING INFrC)EC 110N
<br /> I. Circle;A if above ground; circle U if underground,and circle both if applicable.
<br /> 2. if UNKNOWN, circle; or if t)"I'Illds,print in space provided.
<br /> 3. Indicate the LF AIC I)FIT"(711 )N systems) used to comply with the monitoring requirement for the piping.
<br /> V, TANKTIFAKDfrOb,'OON
<br /> Ind <.t the LEAK 131.t sT,rE 1 i!vS ystco (.) used to comply with, the monitoring requirements for the tanL
<br /> L DE170RN13ar'170N ON SANK PERNIANI"NOX CLOSED SED IES PLACE
<br /> E
<br /> I, IwSITNI.tt"It:D DATE LA T I,„SF -S1ONTTl/"1 Ei\R.(January, 1988 or€}1/88).
<br /> 1 ES'i1S1A `ii)CHUAN t `Y of IIt1SCrlRIX'nU fAr„I3S1"e C f rcmrai rind in the tank.(in Gallons).
<br /> :3. WAS'JANK FILLED Varl"t`I.IJN . '1 MA'Ii.'[RIAI,`? Check 'Ves'or 1NO'.
<br /> I"1'1.TC~ANI` UST'SKIN AND T) 1) '1"IIT,E1'C)It4NT AS INT)IC:A`1H),
<br /> INSU'CI3C"PEON FOR TI1E3 LOC 'II,ACSIANJ IFS
<br /> I fao stair onderg ta,rc cdsnaific a+,can rte mhvr is composed of the: two digit county number,the three digit jurisdiction
<br /> is"rabe°r, t cu vix efa ,Wi ity nurrrbe t anti th. ,ax•digit ank number, "t'he county and jurisdiction numbers are predetermined and
<br /> b.o`e.a.,.a,f b a l ne the Stag Board (916)-139-2421, `the facility number trust be the same;as shown hi foam"A'. The
<br /> tank wunnbcr„;;a3,he, assigned by the local a e n<y; however, this number must be mmicricat and cannot contain an alphabet, If
<br /> ,> foecai ager""y prt ers the `.strati board to i sign tkc tank nurnbtw,ple,.asc leave it blank.
<br /> TI'IS'.1"111.RUSE'C)NISIIIILTI "C)I°`T 1I C T 3C E„ CaE?NC °3 fL ":E°IEd E':C"3 s I EE?E?aAC:T .r:rY'E C) ,iRu ',nir?
<br /> AC°C:IJE2, (:'S O 'T"11P 11olk)RINXIION, THE LOCAL AGENCY ETa RE-SPO S1131.Ci FOR711E MPI.P.-HO OF EFETE
<br /> 'LOCIAL AGENCY USE ONLY*INFO C fA"I"ON TXXX AND FOR FORWARDING DING ONE FORM*A*AND,BIZ' GIKIEE)
<br /> TORO -W(s)TO"1111?P011,0" 'ING 1LTEE)TIE NS.
<br /> 3„e,,; .rTAII^:1C t T SC)S_<' C C:`C3 CE'ETC")TF T :)d RD
<br /> fie T):°TE,
<br /> A'xw ,
<br /> C p., (A abs
<br />
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