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a <br /> 1 I`RU(T11 NS IUR C O PI.I.aI'NG FORM"Ir <br /> G d I I. srI'ucti) e <br /> . One FORM"Ei"shall be completed for each tank for all PER `S,PEMMIT C:1A Cil_<.1.i, Itlx fid"AUS and/or any: <br /> either TANK INFORMA11ON CI G1? <br /> 2. ".I°his form should be completed by either the PERMr.r ISI ITS I'yr the LOCAL A(HiNC Y UNDERGROUND'I"ANK <br /> SI$Iz, FO% <br /> 3. Please type or print clearly all requested information. <br /> 4Use 6a hard point writing instaunaent,you are making 3 copies, <br /> TOP OF I ONLY ONE E"I'IE v <br /> 1. Mark an (X)in the box newt 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 /> I. TANK T)SCRIP110N-42OMPLE"111 All, i S-If'UNKNOWN­SO SP11XxIFY <br /> A. Indicate owners tank ID# >If there is a tangy number that is used by the owner to identify the tank(ex. B70789) <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK M C"a.). <br /> C. Indicate the year the tank was installed(est. 5987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc,). <br /> II. TAN (C) ;'II IN <br /> A. J If MCJ'FOR 1,`111CJI.1s FUEL,check box l and complete items B&C. <br /> If not NIC;Yi'OR VEHICLE FUEL,cheek the appropriate box in section EL and complete items B &11 <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VFIIICL E MEL(if box 1.is checked in A). <br /> I). Print the chemical name,of the hazardous substance stored in the tank and the CAS&#. (Chemical Abstract Service <br /> mummer), if box'I is :"dOT checkc;d in A. <br /> III. 1`ANK COMM.'RU(;ION-MARK C) i"E n. ONLY IN BOX..A,13,Cw&1 <br /> 1. Check only one item inTYPE OF SYSTI:wI..E"ANN MATEJUAL,EIS I'LIRIOR LININ(, and CORROSION PR()"I'E'C`I'IC)N <br /> 2. 1f OTHER, print in the space provided. <br /> IV. PTIIING INIX)RMSfION <br /> 1. Circle A if abovT ground;circle U if underground;and circle both if applicable. <br /> 2. If LINICNOAIN,circle;or if 0111E R,print in space provided. <br /> 1 Indicate the I,E~AK I)E117C.,71 N systems)used to comply with the monitoring're€guirement for the pipit;. <br /> V. TANK I,a C I)MXTITON <br /> 1. Indicate the LEAK DE'T CHOLA systena(s) used to comply with the monitoring requirements for the tank: <br /> VI. INFORMNnON ONTANK PERMANIWIlLY CLOSED IN PLACE <br /> L ESI'I Af,'p D DATE, EAS'1'USE -SEC Nl"CT/Y (January, 1988 or 01/88). <br /> 2. I,€STIMA"1"ED QUAMIT17Y of HAZARDOUS St1B I NC1E remaining in the tank(in Gallons). <br /> 3, WAS"TA:K FILLED iWFI.11 INE>WF a °E I L? Check'Yes'or'NO'. <br /> APHICAN17 mtj,,vr SIGN ANDDATIi1111E IURM AS ) e <br /> t7CI101 I1I11 LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number,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 ()16)739-2421. 'I he facility number must be the same as shown in firm"A", The <br /> tank number may be assigned by the local agency, however,this number trust be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State-Board to assigns the tank number,please leave it blank. <br /> I'"IS I'II E RUSPONSIBUM OF 111E LOCAL AG1 1C 'THNI'INSPI"N"1YE]VA 1 11Y TO°EIRIFY 3 IF <br /> CCU 011-111E RM)VI10 'ITII:E 1 C)C I. G EIEC` 1S III-SPO SIBL E M4 11 .ffl(X)MP1,1TII0N 0,17'111E, <br /> 'LOCAL AGENCY USF ONLY0 1NfT)RMA'I10N BOX AND FOR R DING ONE FORM'V AND t0&SC)GA"i`ED <br /> I R -II-(s)TO11IIE F011.0 WI CE DRE S, <br /> SE)VI" i WltMI IEtiOUR (".()NI"I2()I,1IC) ) <br /> C/o S; .IE.Ikps. <br /> P.O.BOX 52'1 <br /> PIS OUN71',(A 90M <br />