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<br /> INSrMUC TIONS MR til C OMPI.F<`IIG F ORIN'IIS
<br /> OE'Nl!5L,%1,TIN' .<FiUt.,z'3CFNS.,
<br /> 11111n 1,""."M I .niter:,be€.:arnplr cd for cacti tank for all NEWPUMMID,P1?RWI'C.IIANGES, F IlMOVAI Ia trod or<any;
<br /> r,the, TANK INFC.IICF 1ION C11A..NGF-1
<br /> I'la=s worm ashould be completed by either the IIs F AT#III,IC".AMF or the:LO(A x AGPENC Y C}NF) ICCI1tCFL lslly TANIK
<br /> a. TSI I ay �f;rini ca,ar:r all requested sted inforti.ation,
<br /> I. Us(,;a hard poi;rt write,,,.ns.rwecnt, you arc nra n `3,,Lop es.
<br /> TOP 01'I Cy st'I A 'C-)NLY ONE IF—
<br /> EMM-1, g1€ark a n (lk)in the'°box net to the item that best cexct-ihes the reason the form is being completed,
<br /> 2, 1ndic,, the I SIIA cr Facility name where the tams.s instilled,
<br /> L 'I:rk"t�7 IFI:rIC�ICiixiICFN«C:CIIg .r"i"1?AIF1. `I? �-lir I7NFCNC)bN¢ �SI�Ii;C;I
<br /> A. Indicate owners tank 11)# - If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> B. Indicate the name:of the company that manufactured the tangy (ex. FECAL;TANK MFG.).
<br /> C Indicate the year the tank was installed (ex. 1987).
<br /> . Indicate the tank capacity in gallons(ex.25,0M}or 10,M)etc.).
<br /> 11. TANK C;t7N°I`l N 1
<br /> A, P.If MOTOR VERIC,I,'MI T,,check box 1 and complete items I3 & C;.
<br /> 2. If not M(YI°C313 VEHICLE"FUL',L,check the appropriate box in section A and complete items I3& I).
<br /> 11. Check the appropriate box.
<br /> C",. Check the type of MOTOR VE11101"l UTtI,,(if box 1 is checked in C.).
<br /> D, Priest the chemical name of the hazardous substance stored in the tank and the C°.A.S. . (Chemical Abstract Servica
<br /> numbs ),if trey 1 is NOT checked in A.
<br /> 111. TANK C 3NS'I Rucn hi«mARK' ARKoNu,rnm oNI."Y IN BOX A,13,CI&T3
<br /> I. Culrek rataty uaae iteaxa in T�I�Is CSI->SY4't'C?lyri,T,^e"�'IC ittA'I"Ea:1CtAI,I�1TiIZ1�T2 L:CNINCv and C�CIIZIICI3C3ty 1'I2C�1"�`C"1'FC�N.
<br /> IC If C3'111ER,print in the space prttvidcd,
<br /> M PIPING ININ-) I'I FN
<br /> I. Circle A if above ground; circle U if underground;and circle bath if appfscable.
<br /> 2. If UNKNOWN, circle; or if f..3TIIF R,print in space provided.
<br /> 3. Indicate the LEAK DETEICTION sSntem(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK 1XzAK DINTIC7,110N
<br /> 1, Indsc~ate the LEAK DETECTION svFtcn-i(s) used to comply with the:monitoring requirements for the tank,
<br /> VL €NTIO MIXIT N ON TANK P1,M r ANE O: CLOSED IN MACE
<br /> C;
<br /> I. Ii;s INIA ED DATE IAS7F t1S11y-SIC3NMI/Yl:A f(January, 1988 or 01/88).
<br /> 2. a ` VdA'ITd) UAS`1'171Y of HAZARDOUS SI:L3,51'ANC Ei remaining in the tank(inGallons),
<br /> 3. WAS TANK FILLED WITH INET ATERLAL"? Check`Yes'or'NO'.
<br /> APP1..FC`.ANT MUSI'SI .N AND I3.> I`II'1 IF3 FORM AS IND10A°IT0,
<br /> IN .I°II 3MONT FOR711P,LOCAL AGE3NCIIF-S
<br /> he sultr s,rderrr,land st; age tank .dcna ic.acior:number is composed of the two digit county number, the three digit jurisdiction
<br /> uurn c"r, the six digit fa<^iitty number and the six dig;t lunk number, 'Me county and jurisdiction numbers are predetermined and
<br /> a �:4xrt. sac3y ttr it States �Itsaz`i'1 131fs, 3g�2II. L"he facility
<br /> number must be the same as s €xvrz in form "A"a The
<br /> .ai.., s?csi l;k't"Y3'Ya4'M tie«t.4.`ktgT"e:d€;sti a.°fBc kk�%! d?gt,riiy`, i.ryrr-.dei°, this number rtl?tst be t3t[3t3GP`IL'i3l a'A£1C1.C£32'sYi<)2 C47ntat€'s an alphabet, If
<br /> e sr, ! a,et�cy skifets tl." so t,Ix>artl t _�.,.,r the_ank nu bex,please leave it blank.
<br /> 11'I I T111,IIIIta1N3,NSII11111 I CII 'I`I iif I I1CeAF.,AC II C '1lIA LdSI 1 5 This F CILTI'Y `CF VERIFY'i'II1?
<br /> At,"C U ACY OF11M INFr'CIIC A,"IONM 1]IFi L OC.AL ACFIiNC.Y IS RES ONS11311I FOR THE C:OMPLE-111 3N OF'171E
<br /> 'l,CI(;AL A si?NCT USE ONLY'INFORMATION RATION BO .ANTI FOR FtOR A DING ONE FORM*A:1 AND AMSOCIKI i"sib
<br /> FORM`W(s)1`01111i FOLLOWING AIFF'ISI!'S.
<br /> SI° IV OF CA IX)RNI
<br /> C./CI S,r .I:, . ,
<br /> DJVFA F"ROCTSSIN C"I`,NIMR,
<br />
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