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<br /> IN I 77 ZION IDK(X) P1.rt1NCa TiORMW
<br /> CSESNEUW,t l,1D"RUC7I"1C)N is
<br /> 1. One [.,"tM, I3"shell be.completed !or each tmik `or all PE 6 '
<br /> °I , 1sRmn,alANGE, IMOVA113 and/or any
<br /> other'I tt�NK �FORMA`1`O "
<br /> N Cif . £S1?
<br /> 1 `]Tris form should be completed by either the I"ERisir`APPLIC.A 1°or the LO(Yd,.AGEN(N UNDlii2C'aICC)I.7NI3'TANK
<br /> 1N,SISI aC:"1"C)R
<br /> Please s"p.€r print clearly sit scciuwsled information,
<br /> ). UNe a arard point w saasrg sa,strianic a,you are making 3 copies.
<br /> 'FOP C3I=FORM— °SARK ONLY ONE Oil "
<br /> 1. Mark an( )in the box next to the item that hest describes the reason the form is teeing cormifeted,
<br /> 2, Indicastc tire DBA,or i riciiity name where the tank is instalieci.
<br /> I. 'TANK 13ES IPPON -co 1_,ni Au,mus s-71t uNKN ) N--1St3 PE CIPY
<br /> A, Indicate o n n,,ink IN If there is a tank number that is used by the owner to identify the tank(ex.A1170789),
<br /> It. 1nd.cat. the.name of the company that manufactured the tank (en.ACML I'ANK MT G.).
<br /> C. Iraeficazte.the year the tank was Installed (ex. '1987),
<br /> I), Indicate the tank capacity in gallons(ex.25,000 or 10,00()etc.).
<br /> 11. 1ANK CONI`WI
<br /> A. I. 1f M0`1"0t1 VFII1(11i FI FL,,check box 1 and complete items 1.1& I..
<br /> t tics lift."'OR y'I,HK I, ]"Uld-check the appropriate tsox in section A and complete items 13& 1);
<br /> )3. Check the appropriate box.
<br /> C'� C Ire It .,ac type of.\101'011; V1111CLE s I`I1L(rt box I is checked in A).
<br /> I,. rin't the c;la.n'Jeal rourac :,f the 1,�za does snbsto e stored in the tank and the C;.A,S, . (Chemic=al Abstract Service
<br /> number),if box I is'*0Y c h ckcd in A�
<br /> 111, "I'ANK C ON1S1`RUC"11C1N..MARK ONE rll,,M ONLY IN WX A,EI,C
<br /> 1. Check only one item in']NPH OF Sy'S rE .'I'.ANK Mr1`ri,"RIAI,, IN I"I"sIt OR LINING and C'C')I2RO BION PRO`11-,"C"ION,
<br /> 2. If 0111FR,print in the space provided,
<br /> IV, PIPING IMPORMA110N
<br /> I. Circle A itsabove gr und;circle U if once a° round;and circle both if applicable.
<br /> 2. If 1JNKNOWN, c:r'lc" or if 011 HER,1st ant in spice t'ss-ewi ed,
<br /> I indicate the L):AK need to€aa rtply with the monitoring requirement for the,piping,
<br /> 1, fnd..ate the LEAK I11,f i
<br />
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