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<br /> I t�I'RUCI1ONS FOR C 0lNPLIEIIN(3 I )II 'H-
<br /> G 1,-i,
<br /> I3"CI1?NI:R A 1,IN S7I7 REir"IIC)NISe
<br /> f. One I�.';,M "B"shall be corr meted for each tank for all NEW PERMM,PERM171'C' GE-S, REMOVAIA andfor any
<br /> other'FANK ICSIrOR IN1`01st C.'flANGF?
<br /> 2, This f.,t,ra cither the I` oMII' P1, C". `I`or the LOCAL AGENCY UNDE G'ROU D TANK
<br /> 3, Pierce Y f?€, or now cicarly all requested information,
<br /> 4, FISC a i u_d c0int VTjfi _i-ciloMlCat,you arc,making 3 copics,
<br /> TOP OF IX)RIM:'MAJUK ONLY ONE rT-FM-
<br /> 1. Islark an (X)in th €ox maext .o the item that best describes the reason the form is beirig completed,
<br /> 2, Indicate the D13A or YaOhy name where the tank is installed,
<br /> L TANK DENC I ` 01 - OMPI 2 f f ALL I k3 S-IF UNKNOWN-X)SPfX31N
<br /> Aa lndsca' ° o ne rs ,'andlk 11") tf _It'there is a tank rumber that is used by the mger to identiff the; tank(ex. 70789).
<br /> 13, ;nd w,t: the nam of.lac company,pan that manufactured the tank(ex.ACMII `TANK ^CI:).
<br /> C. Indicate the;year tire, lank was h a ails I (ex. 1987).
<br /> Indian,the to,,k capacity in gallons(ex,25,003 or 10,0:0 etc.).
<br /> IT. TANK(C) IIVNI
<br /> A, I.If MOTOR VET FUI J,,c ecI box; nttd complete iteral 11 Z C, k
<br /> 2.If not Mtn"Std VE,111CLE I t�I2_.,c:l_t.k the appropriate box in section A and complete items; 13& D
<br /> , Check the appropriate r;e;x_
<br /> C, Check the type of MOTOR I?a;IIICT FUEL,(if box 1 is checked in A),
<br /> 13. Print the chemical name sof the b azsrch us substance stored in the tank and the.(.A,S. .(Chemical Abstract Service
<br /> numb.), if box I is y OT,he. `nett is A.
<br /> 11. TANK C: I°3.._ UC:`170 I..MAXI(C)2'^II TOM ONLY IN BOX A,13,C:
<br /> I, Cheek,,Fra1y asnc itcat to'z'a"I'I,t;t ,Wy'�I t,�I,,I":5`4tC :�Iz�"f'Ia:ICI�:I,, I�I :sT2IC?42 T_.S:SI4C6 rand C.'t3IIT�C)STi"`3 I'IZC?"I ;C"I"ZC?``C,
<br /> 2, If C'TTIL! ,print in the space, provided.
<br /> I . PIPING INPORAIVNON
<br /> 2. Circle A if above ground;circle II if us dergroun I,and circle both if applicable,
<br /> 2. If UNKNOWN, circle; or if OTHER,print in space prcnidr:d.
<br /> 3. Ftadicalu�the LEAK used to cemiplywith the monitoring requirement for the pipm&
<br /> 1, Indicate the LEi\K Ill.f I,C:`11 N eyste t(s) used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMS110N ON TANK PE"sRMAN:M IL CLOSED IN PLACE
<br /> 1. kC IN ?s'1`,'D DATE' L/\SL`l,1JSa[ n 0 Fll,I'f:,, R(January, 1988 or 01/88).
<br /> 2. s.`II IAT' UA\T1'E'I"'C of f�"rZyRD(IILJS 51'lI5'I'ANC;I remaining in the hank(tri Gallons).
<br /> 3. AS'TANK krL1 LI'll) WITH I`°,'l IRT ` �'f'I ERIAL?Check' es'or'NO'.
<br /> l*PIJC U51'SIGN AND D IT'JITF IXYR I DIC', `IT0,
<br /> I S'M1JC`n0N FOR11117I LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the two digit county sauna§seer,the;three digit jurisdiction
<br /> ,,umber,thesix di-it fxachily ournber,and the*pix�ig4 tank nuinher, 'I'he county and jurisdiction numbers ars:predetermined and
<br /> can be obtained b) calling the State. Iioarcl � `r; 39'2d21, The facility number must be the same as shown its form "A", The
<br /> tank mun air may be assured by the local agency;ncy; however,this number must he numerical and cannot contain art alphabet. If
<br /> the local tame)prefers the State Lioard uo ass4i, tire tank number,please brave it blank.
<br /> IIS IS'ILIII?Rl::r PONSIIIII.,rrk` C.11{THE LC#C:.AL GE C.` YI'II 'I.TNSP['.C."'I 'I.`CI1i IrACH YID VERIFY17IF
<br /> CCU C` OF 11TE INFORMA170N. 11111'IDCAL AGENCY IS RESPONSIBIli,FOR'I I?COMPI.. ,ITON OF 771B
<br /> *..C)(; L,AGENCY USE ONLY'INIX)RMNIION I10X AND FOR MrC3 ARDING ONE 1URM*,W I7 AW)C1IXI D
<br /> IX,) -II s)TO MITI m IpOI.,LOW,ING I.)I IC.I.`R&
<br /> L' L I ; "IE N C.I .C,E C..ONFRO .BOARD
<br /> CA) W.1,.1?
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