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<br /> OFNI: A L INS-17RIiC:I'E£_ENS-
<br /> 1. One FORM "I3"shall be cc>mplowd for each tank fear alis NEW FT,R yt'S, 'UMMI `F C;IIA 't VS, RE —1"V
<br /> o€her'1'AN'KINFOR TTC3':�iC'ID"(317
<br /> 2. 71AN f r:,; ,hould be compictcd by either the PERMTT AIIVL.IkLA�e he LOCAL AGF,NCY 1"JUIW'iW'l,w < 'r°. K,
<br /> EL,
<br /> orsnt clearl-y all requested information.
<br /> 4 Use a of writing instrument.you are making 3 cag+se <
<br /> I QIr r6w P' , E,Y C?NIi Ini14f*
<br /> 1. Mark an(;�` in box,next to the ite-i that best describes the reason the form is being completed.
<br /> 2. Indicate,tl.- pr]'vent name w s the tank is installed.
<br /> °"ANK DES ON -:;N'a�1':]�TE3 ALL TI'F1 OWN
<br /> A. Indicate owners tank I'll# -If Qu d giber that is used by the owner to identify the tank (ex..AI3701789),
<br /> B. Indicate the name of the company t t.. ed the tank(ex,AC:_MI TANK lel°("s.). �
<br /> C. Indicate the year the tank was irstatle (01 6.�. �
<br /> D> Indicate: the tank capacity in gallons (cx. i or 10,0%etc.).,t
<br /> E . '17ANK C;ON'17I N`M
<br /> A. t, ITMO".OR VEHICLE FUEL, check box I and complete items B &C:.
<br /> 2. If not M(.YrOR VEHICLE'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 mo,rOR VEV, 1FUEL,(if box I is checked in A). i
<br /> D. Prim the chemical name of the ia, dous substance stored in the tank and the C.A.S.#. (Chemical Abstract Sei-rice
<br /> ttv `'rj:if box 1 is A.
<br /> 1. Check only one item in TYPE Of'SYSTEM,'TANK NWERIAL,E`NTT RIOR LINING and CORROSION PROTE:,CTION,.
<br /> 2. If OTTIER print in the space provided,
<br /> IV. PIP N,
<br /> 1. Circle A if above ground;circle U if underground: and circle both if applicable.
<br /> 2. If t -<, ',VN,circle:tar if O'HIER.,print in space provided.
<br /> 3. Ince a LEAK T)t JI3CIjEON system(s)used to comply with the monitoring requirement for the piping.
<br /> V 'E:ANK.'LEAK DEM '100
<br /> Indicate; LE"e1: DE,7FF,CI ION systean(s)used to comply with the monitoring requirements for the tank,
<br /> VI. INFORD"170N C'wl'TANK PERMANYMIX 0.)OSED 111N PIAM
<br /> I ES', "D DATE EAST'USED-?vtON"I'I aR (January, 1988 or 01/ft).
<br /> off°. 1) tFIAti 11'J 1 of j ;3;TA\C Eremaining in t6?tank (in Gallons).
<br /> V,A, 'T! '; ;LI I Wt'1'Ei INERT Meas: h. =a_'a Check Yes'or'NO'.
<br /> :',Ea. tt;iz"I ANIS DA11 T'II 3 FORM AS INEWA11M.
<br /> UVII `'i 5C 4 `17113 LOCAL AGT C1[I?.S
<br /> �;round storage tank identification number is composed of the two digit county number, the three digit juri�, W ican
<br /> digit facility number and the six digit tank number. T'he county and jurisdiction numbers are predeterrilmed and
<br /> >bWt l by calling the State Board(910P39-24211. The facility nu -r must be the&ame as shown in form 'A". llar..
<br /> )xk number -,ay be assigned by e 'ocal agency; however,this numb r --,i be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State .rd to assign the tank number,l,, gave it blank.
<br /> TI'[�;''8sx` t, t "e;t�Pislt " '° .i5 ,. .:=.:AGE = a.s1' \,W) F.—IN e"•!.> ... ,. , °',
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<br /> � l�` '�U�t.^�C:',E�N'IL I3C? .� p c ' • ... . .
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