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<br /> IN I'IIIIC.,ITt)Nf1 FOR 1't.:k1".M 11'
<br /> (iI1NI1 I,IIN511RUC'l1ONS-
<br /> ..
<br /> One 1 C1siCyC "li”sl.<=? c=>t9aptc,te i for each tank for all NEW ILII A I"I a,IT, I"1'C'Iii�,'�IC.IIMIi, REMO 1 and/or any
<br /> othcr'I'ANK INFORMATION(1tNGI
<br /> 1 'nis foam, should be completed by ch her the DEEM I'APPIICANr or the LOCAL AGENCY IJINIII:II2£aROUN T
<br /> LNSPI`,C°`10V
<br /> a, Pease trp,,,,� or print cl ati"s'a 1 requested info:nnation,
<br /> �
<br /> 1. , ilse;a ha:�.L point wstfis; you,arc san akitng 3 cc,paes. ro
<br /> TOP OF FORM;'MARK ONLY C3NW fl` ,"
<br /> 1. Marl t n(X)In the box next to the item that best describes the reason the form is being completed,
<br /> 1 Tridic,atc tshe DBA or Facility ntmic where the tank is installed.
<br /> Q
<br /> 1. `1'A N I,)F1,SC RI1Y1"IC ttN-C,°OMPLia"I'It Au,I`I'F3 S-nz tJhimw -so spyu "
<br /> A. Indicate owners tank 11) #-If thea is a tank number that is used by the owner to identify the tank(ex.111370789).
<br /> 13: Indicate tine nxaanc of lite company that manufactured the tank(ex.ACMEX TANKdMFG.).
<br /> Indicate the year the tank was installed (ex. 1987),
<br /> D. Indicate the tank capacity in gallons(ex.25,000 or 1Q,( etc.).
<br /> IL. TANK C ON 3'1"NV5
<br /> A. 1, If MC)TOR VEHICLE FUEL., check box I and complete items 13& C:,
<br /> 2. If nca MC3"1`€7R VE'llICLE,FUEL,check the appropriate box in section A and complete items 11
<br /> 13, Check the appropriate box.
<br /> C. Check tho type of MOTOR VUHIC:'I,1.1"L L'3L.(if box J is checked in A).
<br /> D� Print thn chemical nanny of the hazardous substance stored in tine tank and the C:.A.S. . (Chemical Abstract Service
<br /> number), if box I is NOT chec ed its A.
<br /> TIL TANK C',0NSI"ICt'tA10 -MARK ONV i'E 1 ONLY IN 1t)W)X A,13,C&D
<br /> 1. Check only one item ian'lAIT''l,OP'SY51'EM,TANK MNIT. IAL, LNI`I:T MOR LINING and CORROSION I'IZOTF,C.I'iON.
<br /> 2 if 4)d'€ IEE,print in the space provided.
<br /> IV. PIPING II 1=°C)ICM)VI"ION
<br /> I. Circle A if above g ronnd,circle, U if underground;round; and circle bath if applicable.
<br /> 2, If UNKNOWN,circle; or if OTHER, in space provided.
<br /> 3. Indicate the I,htY'I6 T)ETEC;IION systenn(s)used to comply with the monitoring requirement for the,pa`pi.mg.
<br /> V. TANK LEAK DI T11 X7170N
<br /> 1: Indicate the L13A DE"FEClHON system(s) tis€:d to comply with the monitoring requirements for the tank.
<br /> X11. INFORPYLN110N ONTANK PERM NE N"OX C°TIOSL:a.1I IN PJAC?
<br /> 1. ',`TIM 'l"I'.)1XVIT,LASFUSED-f401 a F}I13'c AR(January, 1988 or 1/88).
<br /> kSi t:al`'I-ED QUANTITY of HAZARDOUS S`~ALMS-FAN(T.�remaining in the.tank(in Gallons).
<br /> 3, 1VAS AN pILLF:E) WITH I N1sIZ"Ii MA U Ir1L? Check'"Yes`or'NC)'.
<br /> APPLICAMr MUSf DIGIN AND DA111 17111 FZORM AS INDICNIED,
<br /> 1°ELI1 I[ 7 F 'e1 ;L,( (:Nl,AGENCIES
<br /> The state underground st rale tank.denlsfacation In ordher is composed of the two digit county number, [lie three di.it jurisdictions
<br /> >numhca the ss atigit f°acilil ,urnbea and the..in dig,st task number. The:county and jurisdiction numbers are predetermined and
<br /> can lie obcannr lay ca,li::2 she State Roard (,9lt0,39-,21!_1. The facility number must be the same as shown in "A". The
<br /> lank tnuntz.c, ,ntay be ua�o s as by the 'saa-xaEaganl,,Vy hovvever, this number must be numerical and cannot contain an alphabet. If
<br /> the local agcncypTefers the .mate a?o,er+.A te, assign i:,c tank nunnh r.please leave it blank.
<br /> II'F:L`TII1
<br /> RH1 SPONSltill XIY 01a°1 11I LY)C Is d1ClIiN "!"fI �It :I IEEx k C LI1"Y' 1 1 I ""I IIx a..
<br /> ACXXRACY OF 1`I1EI NFORNIX1`0N, THE LOCAL AGENCY IS RESPONSIBLE Itt3R71TI:E:?.(lf) I'LINI F OF11114 .
<br /> 'LOCAL L C EINC;Y II II ONLY'IN1 ORNI n"I`IC:N W,.)X ANDW,.) FOR MRWARDING ONE R) "V AND 1 SSOC;I I"1 I)
<br /> FORM 1V(s)TO'111111701..1,0``Usti l DDR SSS',
<br /> SFXTV 17 CSI 1I ORZ 41aS
<br /> NIE '11 liS Ys, CES C°() 'I C)l,BOARD
<br /> C.;CC.)
<br /> F)AII s p c&)C yBliNI G CIL`I'I;
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