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I STRU("ONS FO` CCOM"1 ZING FORM 1P
<br /> GENERAL ECa`L INS 1:II1.,it'I IONS,
<br /> One I OR,1 'R'shall be completed for each bink for all NIEW 1.7 ns,Pu,'Rm ,(1I{INGF , IIII (1VAI-1;ttnd/or<mv
<br /> other°p, 1 1 )L I`I(1a CH G11
<br /> K '1 his forin should be completed by either the PF.RM1TAPP1JCANFor tate 1,0(7d,,. E C: 'UNDERGROUNDTANK
<br /> INSPI
<br /> 13�C,,i £ �')e cr p"'ri 1i t[c ru v h requested infoY`l'nr.€fica"l,,.
<br /> ilxc,s I,.azaa rJrsrn$rvrifiat€;rn5trtanrsxstd<you are,x'naxrrtlt 3 copies,
<br /> OP OF,`1 t RNAL *N4AR O I-11 II_NE U11M*
<br /> irar,. an, (X) in the ox next to the item that best describes the reason the,form is being complcted.
<br /> 2. Indicate the DRA or Fs6hfy name where The tarok is Iasstatleal.
<br /> 1, TANK I L3 ° 111 -C'OMPIXTE All,I IE S-IF'tSNKNO N-SO S ;(I1
<br /> A, Indicate owners tank ID#-If there is a tank number that used by the owner to identify the tank(ex.AB70789).
<br /> is Indicate the nasie of the company that manufactured tate;tars€; (ex.ACM ''BINK MFG.).
<br /> 1„ Indicate the,year the tank was installed(ex,11}£47).
<br /> , Indicate tire tank capacity in gallons(ex.2.5,€00 or'10,( etc.).
<br /> H. TANK C:(") "14 15 ,
<br /> A. 1, If MO 'I'OR VEIIfc,I,I FUEL,check box 1 and cornplete items B& C.
<br /> If not biCl`I`OR VI;1110.,I;I'UL1,check the:appropriate box in section A and complete items 13 &D.
<br /> 11 check the appropriate bow
<br /> C:. t.:Iteck the I ofCT e10tl VIiI IIC;k FUEL(if trox l is checked in A).
<br /> 1), Print the chemical name of the hazardous substance stored in the task and the C;.A,S. . (C°hetnical Abstract Service
<br /> number),if box I is Nar checked in A.
<br /> 111. TANK C,0NS-7R1Jy7110N-MARK ONE rpffe, ONLY IN BOX 13,C&t
<br /> t ih.,. only none heti? to'l'rl£'I„ OF SY' l I:',I,":IA'r,IC MATERML, Iiti I'Fi11IOR IANI G and CORROSION t°11C3"ITC"1'10NI
<br /> I1'Ca"I'3Tl:Et,prion ;n thespace provided,
<br /> IV, PIPING INFORMN110N
<br /> I� Circle A if above ground;circle U if underground;and circle both if applicable.
<br /> If 1_t;�1 '�i€�)�`i ,circle';or if C3'1°11t�T,print in space prr>�4 e .
<br /> 3. Indicate the I,1;:&IC DI,1"1,;C';170N aystcm(s) used to comply with the monitoring requirement for the piping.
<br /> TANK 2.1 10 DINIX-7110N
<br /> 1. Indicate the LEAK DEIhli,C"ZION teni(s) used to comply with the monitoring.requirements for the tank.
<br /> VI. INFORMP TON ONTANK PEii MANENI > CLOSED IN PIACE
<br /> 1. Iii, Flk4YVl'I I3 11AT"Ff IAS`I"USED- torrIj'YFjk 3 (January, 1988, or 01/88).
<br /> 2. ESTIMATED CltdAN'I't'rY of HAZARDOUS UBS'ANC°II remaining in the tank(in Gallons).
<br /> 3. WAS.I NK FILLED D is ITH INERT NIXIERIAL? Check 'Ycs'or'NO'.
<br /> PPI,1(: I'musir SIGN AND I)XIE 111E R)RM AS INDI . I°.D.
<br /> INSS`I2U(NION IrCII133111;LOCAL a1GENC:II1-1-3
<br /> 1 bc.state underground storage tank identificathm number is composed of the two digit county number,the three digit jurisdiction
<br /> number-, the six digit facility nurnber and the six digit tank number. 1'he county and jurisdiction numbers are predetermined and
<br /> an be obtained by calling the.Stag Bahr(](116)73eI•-2421. The facility number must be the sante as shown in fermi "A". 'I'lxe
<br /> task number may b:assigned by the local agency. however,this number must be numerical and cannot contain an alphabet. If
<br /> the local <a-g ncy prefers the (State Board to assign the tank number,please leave:it blank.
<br /> TF IS"1`11(1 RE-RIONSIBUXIT(1Ir°1`E1 I I )C°r11,, CI:I C' 'nixr iNsp -° ai izAc'II,1'r io Ttt 1' '"'11 1?
<br /> ACb`Ill (:,' OF111H INI10R "I'I(1 . 'DIE LOCAs C3IN(-'Y IS ?.S NSIBLI3 T It 11111 COMPLE'DON OF 1111.1
<br /> 1,00M, (SI SI( USE ONLY*INFORMN110N BOX AN13 R)R 1,Y)RWARDING ONE I d2 *Aw AND ASS(1C;INIED
<br /> TN)RM "I(J'1 I1 ItOLLO I 3 ADDRESS.
<br /> I4 11:1 NI"E'R RESOURCES COMFROLI
<br /> , _BOX 527 ,.;�m
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