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I Ix_ 7Ca7ON S KOMPLEIING 0M R.
<br /> 1. One FO wig"shall be completed for each tank for all NFW PE N,PERM171'CHANGES, REMOVAIS and/or any
<br /> otherTANK INFORMATION N IIIA GE
<br /> 2, this form should be completed by either the PERMYr APPLICANFor the LOCAL AGF.N(',Y UNDERGROUNDTANK
<br /> 3. Please type or print d6arly all requested information,
<br /> 4, Use a hard point writing instrument you are making 3 copies.
<br /> TOP OF Icy *MARK ONLY 1NE II7? T,
<br /> 1, Mark an (X) in the box next to the iters that best describes the reason the form is being completed.
<br /> 2. I.ndic.atc ft DII,I or I as ity nettle where the t4nk is installed.
<br /> ID ° A f3 � 1"I C CI111I"IT I1d= S r TI I SI�IC:I
<br /> , Indicate,owners tank 11) # - If titers is a tank number that is used by the owner to identify the 4 nk(ex.A1370787).
<br /> I1 Indican the name of 4hc company that manufactured the tank.(ex.ACMETANK vlt'Ca.).
<br /> C, Indicate the vear the tank leas instal? (cy. 1987),
<br /> I?. Indicate the lark tlipachy it gallons(ex.25,000, or MOOD etc.).
<br /> 11L TANK CONnSNI'S
<br /> A. I. If N-10TOR'r 11110,1" I Iii check box I and complete items 13& CI
<br /> 5.If not MOTOR VEHICLE DUD,,cheek the appropriate box in section A and complete items B& D.
<br /> 13, ("'heck tnc� ap ropri ate bcw.
<br /> C. t he khet €e of O(y`I tti�V IIIC I FUEL(if box 1 is checked in =h}.
<br /> 11. Print tha chemical natne Cif the hazardous substances stored in thetankand the C.A,S. . (Client
<br /> Abstract Service
<br /> number),it box 1 is NOT checked in A,
<br /> III, TANK OMM C7 11 N-MARK ON1, num ONLY IN W)X A,IL,C>
<br /> 1, C l c'rk ass.,, one item, .:rt'ry pr'OF S'a STE' , 5"l NK:'fi t"FERIAT,, I FFRIOR 1JNING and CORROSION IlRbrI"Ii.0:.'.1710':°e.
<br /> 2. 111 OTWIER, print to the xpacc provided.
<br /> IV. PIRING INI°ORMA'I'ON
<br /> 1, C',ircte A if above ground; circle U if undcrground; and circle both if applicable.
<br /> 2. If 1 N Na °'s r OTHER.paint in space provided,
<br /> 5. Indica,, the LFY',r" ,Il',I l _"I2t5 s .x ts:us)used tan compiv udth the rnomforing requirement fe r the pipin& ,
<br /> T. `I`ANK LFAK Iy'a f`11717t;:;ti
<br /> 1.. Indicate flie 1,.,x K IC >1 F(T ON syslerta(s) usce7 to cornply with the anonitoring,3 requirements for the tank.
<br /> L ITT=CIIC AIFION ONTANK FR.MA I"1 A CLOSED IN PIACE
<br /> 1, FSFIMATED DATE I SI`T;k,l t5-MOYTTIfYEAR(January, 19 98 or 01j83).
<br /> 2. ENI'IM 11'-13 Ok,' t "I1T Y of IISZ,r'tS.DOUS S1,B51'?.'SCIi
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