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EI S'I'RtJS"I'ONS'110 II £°£IES PI Tql NG I B.
<br /> £3I; IIfIIAL Itxlarl IaU t II NS:
<br /> 1. One FORM`°II"shall be cormdelec for each tank for all NEW PERMF13i,PERMUCHANGES, REMOVAIS and/or any
<br /> 1 Ellis form should tae;completed tag chher the PIIIL I'1'e4PIIIAI£"AN'll'or the I,t3Gt.,. (3E3 UNDURGROUM)'FANK
<br /> 3, Please type or faint clearly all requested inform atioa.
<br /> 4. Use a hard point wiring;nstru na at, you:are making 3 copies,
<br /> 1'0111 OF FORM, 'MARK ONLY ON11f 11-U"1W
<br /> , blark,:ar tib) i=.I the Ealy ncxr to,.lata been €heat best describes the reason the form is being completed.
<br /> 2, Indican the I'BA or Facility name where the; tank is installed,
<br /> I. 'rANK DIS" " *I°TON-'£;£) I,1`F ALL TIE - I'IJP O -S£)SPECTIrY
<br /> A. Indicate assurers tank 11)#M If there is a tank number that is used by the owner to identify the tank(ex.A1370789).
<br /> F3, Ir ficaa , ahc name,3t 'he _„taaaaany that rnar.ufeacturred the tank (ex.AC ME'LAN FG.),
<br /> C. Indicate the year t,re t ek w-as inaaalled (ex. IfA3
<br /> I). hndicaae the tank capacity in gaHo as(cx,15,0X or l0,0sU etc.).
<br /> IL 'FANK CONIEN'US
<br /> Ay 1. tl Mfl"1` le 1r- f lat".:L.= FUEL,check box I and complete items II
<br /> 2, If not `<-Iry-a_,R V IRC LE FUJI_,a,I e,-k tar:appropaiat=box in section A and complete items 13& D.
<br /> P. £ ca k the.app•c prime le'-".
<br /> C, t`hcck the tr e of It:a`IrIIZ V111 C Z I 1,UEL,I (h`box 1 is checked in A).
<br /> I), Pont €t,c chemical n,arne of the ha.ar>ouF subs*ance stared is the tank and the C:.r"a.S,W, (Chemical Abstract SeMce
<br /> number). if box I is O'l" hair ked it A,
<br /> III. 'I"ANS oms,mu on£I -IMARK£I E<1711W ONLY IN BOX A, B,£1& 3
<br /> I_ Check only one h to in FYPE`;OF SYS f'l7,M,'I'A N "I`i1I�I� ,, IN'[PRIOR LINING and CORROSION PRC.`[`F;£:FIO .
<br /> 1 If 1`I1I IL,print in the sliace provided.
<br /> IV. PIPING IFORMATIO
<br /> I. Circle A if aborve grc.nndl ei-rale Lr if underground; and circle both if applicable.
<br /> 2, 11. U'N O r it.le; c r H7t:`s'I`bllip,print in space provided.
<br /> 3. Indica€e the LEAK fll3p I`C"110N e s:_rn(s,used to comply xith the monitoring requirement fest the piping,
<br /> i. Indicate the LE,,N ,)�;I,£.l'"l£)� �tsaent(.,) used tta eoniply with the atorrtoring requirenients for the tank.
<br /> STI. I LI£3 a dl£} I. N"I°zkNK PERMANEIV11M CT,,O SIffD IN PIACE
<br /> 1, I;SI'Iiylr�'E"�L3 C��'t"I'?E�riS'f`L SI sa"a_IvII2� fI i"x'L',�.IZ(7anuasy, 1I�gS c:r4'�£Ig).
<br /> 2 r si imi1`t°1?I)(f,:y 'I I: 'of HAZARDOUS SUMS"I°ANC , remaining in the tank (in Gallons).
<br /> 3. WAS`1.�.�K FILLED ED ILII Check'Ycs'or'`O%
<br /> APPIIE.it mi-fs-r SIGN AND I'4VI`1r`I1IlF MRM, S I III£m I`I:3.
<br /> 6N' fG"R 07110 FOR1111, LOCAL L, GEI CIE S
<br /> "f he state,underground storege tank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> saaznnbcr,the,sig dagit fackity namber and the sax digit tank nurnbe:r. "I'he county and jurisdiction numbers are predetermined and
<br /> can be obtain d by r f ng the State Board r4L a}1 " alZ1, "I'lie£zcilaty number r aunt tie the same as shown in farm"A". The
<br /> lark,number ma;be 6neipice by the local agc ncy; however,this number must be numerical andcannotcontain an alphabet_ if
<br /> the kx"a's agency prefer--,the State Board to assign the; tank number, please,leak it blank,
<br /> ACCI I £'Y£I111'IIE1 INFORMA710N. III LO(:AL AGENCY IS IIIISPO SIBLE FOR 111 C OMP11-FIT N OF'I'IF
<br /> 'L CL L AGFNC`Y USE ONLY'It O BOX AND OR FORWARDING ONE FORM W AND A C 1T,,D
<br /> Ez£1II "II"(s)°I'£ `E II?E 1I,I:£I '1NG ADDRFISK
<br /> RI`s1713, NII? RESOURCIN!' I :IROL BOARD
<br /> cA)S. r.E?l Ps.
<br /> DNEA PIRX, SING (TW. 117R
<br /> RCe IX)X 527
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