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r ITIUL N It NS IDR COMPIXIING FORM m1T
<br />(IIINE,RALIN UC31
<br />(. One T°C) "B' shall be completed for each tank for all NEW PER 1`S, PIT I°1' QI GILL% 1:3 C)VA 3 and/or any
<br />other TANK IMA)RMAMON 01ANGE
<br />1 This form should be completed by either the PERMrr APPLI(YiNTor the LOCAL AGENCY 1J` II C C�'LIND TANK
<br />' SMB
<br />:3. Please tyre or print clearly all requested Information.
<br />4. Use a hard paint writing instrument, you are snaking 3 copit s:
<br />TOP Of' FORM: 'MARK ONLY ONE M
<br />1. Mark an (X) in the; box ne ars the item that best describes the reason the form is being completed.
<br />, .. 4 A,: name where the tank is installed.
<br />`gym,
<br />. TANK SC IP'11 4 ., 0IHr All, Ill. ' S - W UNKNOWN SO SPFAMIY
<br />-
<br />A, Indicate owners tank. Iii # --If there is a tank number that is used by the owner to identify the tank (ex. AI370789), ..
<br />11 Indicate the name of the companythnt, amanufactured the tank (ex, ACMETANK MFG.).C:, indicate the year the tank was installea� ex. 1987),
<br />I). Indicate the tank capacity in galla • (ex. 25,000 or 10,000etre~:
<br />IL TANK C ON I1,W115
<br />A� 1. If MOTOR VEHICLE FUEL; check box 1 and complete items B & C.
<br />1 If not MOTOR "VEHIC;I, :: FUEL, check the appropriate box in section ,A and complete items T3 & D.
<br />B, Check the appropriate tams. g;
<br />, Check the t of MOTOR VEHICLE FUEL (if box 1 is checked in .A), "
<br />D, Print the chemical name of the hazardous substance steered in the tank and the C;.A.S. ". (Chemical Abstract Service
<br />number), if box l is NOT checked in A.
<br />I i. 1 ANS C C)NS aCP11C)N -W,CM3 ITI O ,' 13() A, 11, C, D
<br />1. Check only one item in TYPE OF S" STEM, TAMC f+ A'IERIAL, INTERIOR IOR LINING and CORROSION J'ItCIT CI' ON.
<br />2. If OTHER, print in the space provided.
<br />. PH INC,NI ). X11 N
<br />1. Circle .A if above ground; circle Li if underground; and circle, both if applicable,
<br />2, If UNKNOWN, circle;if TIER, print in space provided.
<br />3. Indicate the TWIB..AIC DETi: N systern(s) used to comply with the monitoring requirement for the piping.
<br />` "1ANK IsEAK DIr1 r 1ON
<br />11 Indicate .the LEAK DFIT,(-,,TION system(s) used to comply with the monitoring requirements for the tank.
<br />VI. INFORM.A11ON ONTANK ISI? AN .W11, (in IN lei 7
<br />L T -S'1]N4A'I`ED I -1— LA9r USED - MONI'll/1 II (January, 1988 or 01/88).
<br />1 T",5 IMA'TED QUAINT] 'i"T°Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br />3, WAS TANTO FILLED WITH INERT MATERIAL? Check 'Yes' or 'NC)'.
<br />APP1,1C"..AN'1 MUST SIGN AND DATE MIR MRM AS IN1)I : n,a).
<br />1N51'R1JC.110N POR 71-III 1A)C"AL ACIE$NNC:IIBS
<br />The state underground storage tank idendeNtion number is compose ,of the two digit county number, ihe,,thre:e digit jurisdicticsai:
<br />number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined aftd,.t,.
<br />can be obtained by calling the State Board (930739-2421. The facility number must be the sante as shown in forst "A'. The
<br />tank 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 />I1' IS 111E. RESPONSIBI1117Y £3171111{' .C)C ACllB 'I I `Ie IN DC IS "1'111: 1a.AC®11,1` TO VERIFY'I11I?
<br />ACCURACY U OF THE INFORMN110N. '17112 1,OCAL AGENCY IS RKSPONSIBLE la "111 C"C LE`11ON OF 11108
<br />*LOCAL AGENCY USE C)NLY* INFORMA110N BOXAND FOR 1 11' AR ING ONE FO M 'A" .AND '1"Tai
<br />PX) Ir(s) TO 111 I tI I) ;;SSA
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<br />ffi (,„°....+ttw'*,gpvyl'n&
<br />S�rAT WNI'ER RESOURCBSC"C) 1' Cli BOARD
<br />.
<br />C/o Sea n:5
<br />DKIA I' C)C: x S C1'C.. f' R
<br />PD. BOX 527
<br />PARAMOUNT, A WM
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