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l N TJ , CANS FOR COMPUZIING 1URM'Ir <br /> GINERAL S°I72LJC"17ONS <br /> 1, One FOR "El"shall be completed for each tank for tallFPI? N, PERMIT C:F G S, REMO AFS and/or any <br /> other TANK INF ON C1IIA GrR <br /> 2. This form should be completed by either the Ptlkwr MPUCANr or the LOCAL AGFNCY IJ I?II;Ca OUND 17 <br /> w- `w 1 Please type or print clearly all requested information. <br /> 4., Use a,hard point writing instrun ll ntC- ou Are�M king 3.go <br /> POP OF FORM--MARK Ok4l.Y ONE n-im <br /> 1. Mark ars (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the IBA or Facility name where the tank is installed. <br /> I. TANK FAIL "R CyW' MPIHM?ALL I'I. -1114 UNKNOWN-So SPE(3FY <br /> A. Indicate owners tank ID # w If there is a tank number that is used by the owner to identify the tank(ex.tAB70789). <br /> B. Indicate the name of the company that manufactured the task(ex.ACME T ANK MFG.). <br /> C. Indicate the year the tank was installed(ex.1987). <br /> I). Indicate the tank capacity in gallons(ex. 25,000 or 10.000 etc,).$ <br /> IF. TANK C OISMINT a <br /> A. 1,If MC9'I`OR VEHICI..I?FUEL,check b€ix,I and complete items B C. <br /> 2, If not MOTOR VEHICLE FUEL,check the appropriate box in section fA and complete items B&'E). <br /> B. Check the appropriate box. <br /> C< Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in F1). <br /> I3, Print the chemical name of the hazardous substance stored in the tank and the C.Q.S. . (Chemical Abstract Service <br /> number),if box 1 is NCDT checked in A. <br /> Ili. TANK CO rRUC 17ON-MARK.oNfi nym om IN Box tA,K C&I3 <br /> 1. Check only one item in TYPE t3F SYSI'ENC T NK' .ATE' I L,INI`LI1IOR LINING and CORROSION IaIZC3°IF(7110N. <br /> 2. If O I[I IC,print in the space provided, <br /> . PIPING AOR TION <br /> L Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 1 If UNKNOWN,circle, or if OTHER. print in space provided. <br /> 3, Indicate the LEAK DETEI , .ON system(s) used•to comply with the monitoring requirement for the piping. <br /> V. TANK LFAK 13I:'`FX7IIt1N <br /> 1, Indicate the LF AK DEIE ON system(s)used to comply with the monitoring requirements for the tank. <br /> . INFrf 3 'n0N ON TANK PER NENI (MOSED IN PIACE <br /> E <br /> 1. ES'I11a NPE?ZD DATE I.AS USE;I)- 01-,1.F1/YF:AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY Y ref HAZARDOUS SIJB,5FANCE remaining;in the task(in Gallons). <br /> 3. WASTANK F CI.,I.:I LB IT 1 IN tt"I'MATE<I2[fAI?Check'des'csr'NO', <br /> tAPPLIC" 1'MUST SICK ANT)D I11°Ill yFORM AS INDIt NI = 7. <br /> IRUC'11ON F 1C nII3 LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction <br /> number;the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the`Mate Board($316)739-2421. The facility number mast be the same as shown in form 'fA". The <br /> tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT 1,5711W, ON%IB 1 `01111111 LOCAL Ca t~'Y°i'II `I'INSPF? I '1°II3 I?A('II:I 'F)0 VERIFY111E <br /> ACC U C OFT1111 INFORMNITON. IIIE LOCAL tA(l:oN(7Y IS RENPONSIBLE FOR ITIE CO . l In ION OF 71 B <br /> *I I,AGENCY USE CI FLM II[ON W)X AND FOR FORWARDING ONE,E If *A"AND A.S.SC 'I IF3 <br /> FORM-W(s)TO 11111 MLLOWING t1DDRE S, <br /> PAM,, tAi R RESOURCES CON17 OL BOARD <br /> C/o smaaps. <br /> DJVrA F'B 'I SSING,t:Is" PER <br /> P.O.BOX <br /> �' w <br /> PAR taC7C7 '. Ch 9VZ3 <br />