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FOR U c. 1 I G K)R@. a It
<br /> r„ 0-m" FORM I 'R,shalt be completed for each tank for all NEW PERMTl3,1$1 11 I'f'C;IIANG.?S, 121f:Ar OVA .`3 anti/or any
<br /> otherTANK INIaf.R A°170N(711AT G17-
<br /> 2: This formshould be completed by either the PER PLd' or the I.)C',A1,x AGENCY U 'h)IIItGRO IND 7 A3
<br /> 1 please irpc,or pr=int clearly all requested information.
<br /> UseMARK C)1Y1..Y oinwt eitzrtg instrument,you are making 3g1 s}rc,.
<br /> 44
<br /> C)P3
<br /> `IUP OF '
<br /> 1. . mark an ( in-the 1ox-next to the itern that best describes the reason the fouls is beingcompleted.
<br /> 2, lidicatc,tite I313A or Facility name where the tank is installed.
<br /> I, TANK 1)1.fit`,'R1 YI1'0N-•COMPIINTi AI.:L IITIMS-II?UNKNOWN-SO SPIX31
<br /> A. Indicate owners tank 11) #-if there is a tank number that is used by ttae owner to identify tote tank(ex.A1370789), *i.
<br /> 11, Indicate the naane of tire company that manufactured the tank(ex.ACMI..,TANK MFG,) �
<br /> C',', Indicate she year the tank was installed (ex. 1987),
<br /> T'). Indicaate the tank capacity in gallons(ex.25,0or'10,000 etc'.),
<br /> IL TANK CC) 1` 1
<br /> A, 1. If MCy'.'O VE'llIC,1,I;I``UEI„,check box 1 and complete items B& C
<br /> 2, If no, MOTOR VI.J110-13 FUEL,;check the appropriate box in section A and complete items B& D.
<br /> 13. Check the appropriate box.
<br /> C Check the type,of MOTOR VL111C I. i UElf.(if box"L is checked in A),
<br /> 1), Print flv,;chc mical mane of tilt,hazardous substance stored in the tank and the C-A.S, . (Chemical Abstract Service
<br /> nuns e:.), if box I is NOT checked in A.
<br /> III, TAI (X) ST `A ION..bMRK ONE ftlfffoot t)Pdt.,Y IN BOX A,13,C:&1)
<br /> 1, Check only one ileus in TYI'f:OF SYS`L`JSM,TANK MA'ITIRIA1., INTFERIOR I JNI G and CORROSION I'32C`rE1'(TI1ON.
<br /> 2 If 0)111,ail,print in tilt:space provided,
<br /> IV. PIPING INK)RJAKI10N
<br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable.
<br /> 2. 1f UNI et:1WN,circle; or if C)I'11ER,print in spaace,provided-
<br /> 1 bidica<e chc 1.,�-',A used to comply with the n onitor-in :retgchrcnarm for the pilling.
<br /> 1, Indicatc,the I,Ev'IK h)fTf`(:I[t)T systems) used to comply with the monitoring requirements for the tants.
<br /> VI. INFORMN110N ONTANK PERMANENIT.,YU,101SE T P1,ACE
<br /> 1, E,S`II"tlA” EJ) DNIT L.ASF USI I:)-MON`l'l1/Y AR(January, 1%8 or 01/88).
<br /> 2, LS11MA`1ED QUAYFI'1"Y of 1A7,'kR OUS SL:B51ANC E rema;ning in the tank(in Gallons).
<br /> 3, : A4 FANK 1'11a1,UI) WITH INERT ATFR ? Check`Yes'or°NO'.
<br /> A '..C".A `I'MUST`SIGN ANI)17A"1 HIE R)RM AS i .IC IID,
<br /> INS17RIX 170 FOR11111 ,C) Ai{A€ENC IRS
<br /> The state aa_ad.crground star•al hink identification number is composed of the two digit county number, the three digit jurisdiction �
<br /> number,the six digit facility number and the six diig,h tank number:, The county and jurisdiction numbers are predetermined and
<br /> call.be obtained by calling the,State Board 916)7YI-242 . The;facility number must be the same as shown in form"A'. `file
<br /> tank nutntaer may be assigned by the local agency; however, this number must bte: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 /> TFUS ILIE k H-SPO SIBIlp,-Y OF-171E 1k)CAl,a GENC; "11NI°NS'I °1111 1aAC'€LY1 Y ro W—,RT'Y 17113 _
<br /> ACC'URACIY OFTHE.INFOR TIQN. .11,11E 110OA1,AGEN(TY ISI° '11111 ) i"1.Imo of n1I1
<br /> I AGENCY iC Y USE 0i L 1 i Ta `Til) I PA,,)x Amy IUR I C) 'A"AND ASS)t, "I`1
<br /> FORM"W(s) 011 1I 1701,11)WING '? y
<br /> LII"A'113 Clot CAI11Fk) lA i
<br /> c°jo S.M6 ulps.
<br /> DXFA P .("It'1IS.S U CT I'
<br /> .C),BOX
<br /> PA. I C)UNr,C°A ,
<br />
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