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<br /> 1,NSW L,tC'rT£1N;S r .1lt;C OMPI.r.rITNO MMM'13"
<br /> (.STNURAS, IN 1` 11t..;1CfN %
<br /> I. One `11 sha=be ,omn land for each tm-a fc)r gall NIV. PIMMM.,I' ; rI`C HANGF , ICt;1 C' AI:If and/or anv,
<br /> W. ?his s t ,.;:,a shea ';d#af 4 casaa alcfc f l,y°either the ralE.11 Ir'.AT'Ir1,rC:A1"or the C7C° ACs1:?TIC 13Pd11T"s1YC=1tC)Tf1T"tA
<br /> INSPFICIMR,
<br /> _. ,a, Pleasc ..ype or prult olci athd all requested information.
<br /> 'I. [Jsc a ,.ard point vv i�n,C instaasncm,you are.long3 copies,
<br /> .gip€ P OF FDR14.*Nb`,,RK* `,,RONLY£SNI.rJ1F
<br /> 1 Ta k ari(X)ill the Taos;LeKt`, ;the item that best describes the reason the form is being completed.
<br /> Indicalc,the IMA or I a i3ity name where the iank.s installed,
<br /> L 'TANK 131 I IT C r..ISI°IT ALL 1"L -IF UNKNOWN. O1°3,
<br /> FT, frobcate ownrers tank ID #- If there is sa tank number that is used by the owner to identify tite tank(cx,A1177789).
<br /> & Indicate the name of the company that manufactured the t6nk_(ex.AC F?`1'AWTC MFG,).
<br /> C. Indicate the year the tank was installed (ex. 1987),
<br /> D, Indicate;the tank capacity in gallons (ex.25,000 or 10,000 etc.).
<br /> IL TANK WNITWIN
<br /> A, 1, If rTCT'I'O V fTIC,I,I,T UIFL,check box I and complete items B& t:.
<br /> 1 If co, MOTOR`'EMCL,I F1 1-1—check the appropriate box in section A and complete item, I3&T).
<br /> B, Chcick zhe appropriate box.
<br /> +. Check, ",,e tv,e o "01F tf x 1,11..( z,1,FUM,(i1 box "I is checked in A).
<br /> rt print the chemical mical loo-e of the hazardous substance stored in the tank and the£",rA,S. .(Chemical Abstract Service
<br /> t7armx,y),i<lox ?. is NCy r checked i;,A,
<br /> TTI: TANK C°ONST°1CUC"I ON m MARK(mica rllt'm ONLY d B(JX A.,11,C'& 3
<br /> I, Check only one iters in"I'YPF' 01 iN ['IM,"I"<A1eIC LA'1 I:F�I�iI, I NU'EsIt OR LINING and (,70FIRO SION 1'i2C"1`I'EC.I10114.
<br /> 2, If x�YII EM, print in thc space, s r€,e"i.,arl.
<br /> L Circle A if above ground;circle U if tu"Oergyo and,and circle both if applicable.
<br /> 2. If UNKNOWN, circle; or if C;r`iHFI ,print in space provided,
<br /> 7, Indicate the LLSAK I)1 Tl;C'7100 sy-sfcm(s)used to comply with the monitoring requirement for the piping,
<br /> 1, Indata€.: the LUM f'3 1 TxC°I`I0 slstern(s) used to comply with the monitoring for r'the tank,
<br /> V1. I FORMU TON ONTANK PIIrf ANTWI'L'y CLOWD IN PLACM
<br /> 1. `1`IMz AFD DA'r°I' LAST USE',])-M0N I i AR(January, 1988 or 01/88).
<br /> F-S'1 MATFI7 QUANITFY of ILk7ARDCTUSS`sUFEST,a4,\NC"I:remaining in the tank(in Gallons).
<br /> 3, WAS'IANCFILLFl)WITH INEICF;' AI"TI IAL? C'.heck'Yes'or'NO'.
<br /> APPHC;ANI' C1 1'SIGN AND TTATI9`I FORM AS I DIt NIT T.
<br /> INSTRI1£°110FO "1111 L 0NI"AGITNCIES
<br /> The,state underground storage tank identification ncrabe r is composed of the two digit county number, the three digit jurisdiction
<br /> nurxaber, the six d a,rt facility r;car_aba,r and the six digit tank number, `llae county and jurisdiction numbers are predetermined and
<br /> can be(t)€.,used by caring al..c Stat.. Bo,,ird (€at,.)1C"r-242"1. The facility number must he the same as shown in form „A,`. The
<br /> tank nunn'ber may he sas,,
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