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W,'J'RU(.'1'T0NS y�^y R COMPLE'ji-114f
<br /> (IFNERAL INSURUcnom.-
<br /> L One FORM "B'shall, t,e coirpicted 'or each tank (or all NEW PERmns,PEIRMIFI'U.Vl�NGHS,
<br /> other 1ANK IMk)RM-A11ON('11-NNGIL
<br /> 2. This form IV covnplctcd by either the PER WI'APPI.ICANT or the IOCAI,AGENCY UNDERGROUNDTANK
<br /> fN,SPECfTtR.
<br /> 1 Pic asc cleajlv all rc(-.-u(-,ted ifformntion,
<br /> 4Use a harj
<br /> point wrip;ng amus merit. you are making 3 copi4s.
<br /> j
<br /> 'MARK ONLY Cam I'1"
<br /> 1. Mark xm (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicata.e� F,4 tits nay'ne where the tank-is instil'ied, .4—
<br /> -IWS 'SO SPE91n
<br /> '&*1D4-L4,R1P1" 014AP1.13111 ALL T1 -J17 UNKNOWN-
<br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank (ex.A1370789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACMF,TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1.987).
<br /> D. Indicate the tank capacity in gallons (ex.25,0W or 10,000 etc.).
<br /> 11. TANK COM11WI'S
<br /> A. 1, If MO"--,R VEHICLE FUEL, chick*bot I ah6,6o?,",- .. ...... 3 &C.
<br /> "OR VEHICLE"FUULcheck the appropriate, bux in section A and complete items B& 1).
<br /> B. -,,-,-Opriate box,
<br /> C. ,he tvPC of MOTOR VEHIC1.1.7,FUEL(if box I is checked in A).
<br /> type
<br /> 1). L the chemical name of the hazardotis substance;stored in the tank and the C.A.S.#.(Chemical Abstract'�kervice
<br /> number), if box I is NOTchecked in A.
<br /> III. TANK CONS RUCTION-MARK ONE rrEm ONLY IN BOX A,13,C&D
<br /> 1. Check only one item in'TYPE-:OF.SYSTEM,TANK MATERIAL, FNITERIOR LINING and CORROSION PROTEC110N.
<br /> 2, If OTI]Lift-print in the space provided.
<br /> IV. PIPING IN]FORWYFON
<br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided.
<br /> 3. Indicate the LEAK III TECIION system(s)used to,comply with the monitoring requirement for the piping.
<br /> 1. Indicate the LEAK D1:1111.1,CDON system(s)used to comply with the monitoring requirements for the tank,
<br /> VI. INY-T)RMKIION ON TANK M I.NAANFNPN t7f OSVI)1N PIACI::
<br /> 1. ESnMATUD DX1.13 LAST USED - MOINTII/Y[AR(January, 1988 or 01/88).
<br /> 2. ESHMAT131)QUANTITY of I LAZARDOUS SUBSrANCF.remaining in the tank (in Gallons).
<br /> 3. WAS TANK FILLED WrIII INERT MAWRIAL? Check'Yes'or'NO'.
<br /> AppucAmr MUST SIGN AND DA11:1 IIIET FORM AS M. )ICAWD-
<br /> INS TRU(7110N FOR111137 tDCAL AGINCIES
<br /> 'Me 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 Boar4(916)739-2421. The facility number must be the same as shown in form "A". The
<br /> tank number may be assigned by the local ageocy; 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 /> UISTHE I SPONSTRI r' i. a1 iI lA1 111""al V1 V '11-1E
<br /> A
<br /> -Y -1111�IN IS Rl"CCURAC . OF
<br /> ",� I
<br /> 41,0(:Al,AGENCY USE 01-� 411,:
<br /> R)RM W(s)TO-rI W,RX,Li,,
<br /> W)AW
<br /> sill ftlimb..ii4, CO
<br /> DXIA PROCESSING CFfq-
<br /> P.O.BOX 527
<br /> PA MOUNT',Q\tXYM
<br />
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