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EN:SI"liU . 1C)NS MR COMPUTIING I?O 'I3* <br />GENERAL INSIMUC110MR <br />1. One Ert)RM "fare shall be completed for each tank for all NEW a °IN, PERMIT CHANGIiS, REMOVAIS and/or any <br />other TANK INFORMATION C 11ANGF <br />2. This form should be completed by either the ILII CI APPUCAN.r or the IOCAL AGENCY U , E RGRO °I°ANK <br />INSPI.DCrOR. <br />s 3. Please type or print clearly all requested information. <br />4. ase a hard point writing instrument,you are making 3 copies. <br />71100 OF FORM.'MARK ONLY ONE I°IIm .E <br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br />2. Indicate the DBA or Facility name where the tank, is installed. <br />L SANK INIkSCRU.111 N - COMPIPEFE ALL MIMS - IIx UNKNOWN - SOSPI <br />A. Indicate owners tank ID # - 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 tank (ex. ACME TANK MFG.). <br />C. Indicate the year the tank was installed, (ex, 1487). <br />D. Indicate the tank capacity in gallons (�x. 25,000 or 10,000 etc.). <br />II. 'PANIC colo zm's <br />A. 1. If imiCETOR VEHICLE I i I:iE,, check box 1 and complete items Ii & C. <br />2. If not MOTOR VE EIIC LE FUEL, check the appropriate box in section A and complete items B & D. <br />B. Check the appropriate box. <br />C. Check the type of MOTOR R VEHIC;I,I' FUEL (if box I is checked in A). <br />D. Print the chemical name of the hazardous substance stared in the tank and the C:.A.S. .,(C'hemiial Abstract Service <br />number), if box I is NOT checked in A. <br />111. TANK CONST RUC 11ON - MARK oNri ripm ONLY IN 13OX A, R, C & II <br />1. Check only one item in TYPE OF SY,51 .M. TAMC MATERIAL I,NI"LI,II.IC)IR LINING and CORROSION PiZC1TE . ON. <br />2. If OTHER, print in the space provided. <br />IV. PIPING INFORMADON <br />1. Circle A if above ground; circle U if underground; and circle bath if applicable. <br />2. If tjNlCi'~dOWN, circle; or if OTHER, print in space presided. <br />3. Indicate the I,liAK I)h-rl1C710N system(s) used to comply with the monitoring requirement 1`(�r the piping. <br />V. TANK LEAK DUFF ON <br />1. Indicate the LEAK F) C)N system(s) used to comply with the monitioriing requirements for theWIN,k. <br />VI. INFORMATION ION C)N T PER Ibli. LY C DSI ) IN PAC <br />1. E.S""IIMNI'ED DATE LAST USED - IvlONTFI/YE: AR (January, 1988 or 01/88). <br />2, ESTIMATED ED QUANTIT of IEA7ARJ)0US SUB,51ANC:E remaining in the tank (in Gallons). <br />3. WASTANK f'II.I.,ED WFFII INE3RT MA`L`E AI,? Check 'Yes' or NO'. <br />APPLICANT CIS SIGN ANIS DAII1'1IIIg FORM AS I 7 7 ::1. <br />INS'I'RUCIY N FORHIE IA)CAL AGENC IE-S <br />The state underground storage tank identification number is composed of the two digit county numbcr, the three digit jurisdiction <br />number, the :six digit facility number and the six digit tank number. > The county and jurisdiction numbers are predetermined and <br />can be obtained by calling the State Board ({716)734-2421. The facility number must be the same as shown in form "A". The <br />tante number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet: If <br />the local agency prefers the State Board to assign the tank number, please leave it blank. <br />rr Is nwREsPoNvBnxff o "nw LocAi. AGENCY 111ATINSPIX,71S 111E FAC11,17INTO VIIRI17Y TIIi? <br />AC (''.0 C 0F'17TE INFORMA770N. 111E IOCAL ACII;NC"X IS RNSPONSIBIE FOR 1117 (;C) PIJr1'IUN UIQ `i°iIE <br />*LOCAL L AG USE ONLY' INFO A'110N W)X AND FOR FIORWARDING ONE FOR "A* AND ASSOCIA717ED <br />FOR qr(s) TO `11111 FOLLOWING I)12ILS.S. <br />OF CAIBK) NIA <br />A s WATER RE-SOUR(JN Cot? `EtOL ]BOARD <br />P.O BOX 527 <br />PARAMOUNT, <br />z <br />