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<br /> I C 11O S ItOR COMPLUFING FORMW
<br /> I. One 1 c.f ;.1kl 'II"shall be €.°oninla tcti For cacti him,, fio all NFW PERMTRS,PERM'I'C:I NGES, I I> 0VA1 S and/€rr any. '
<br /> other I`AN:IC INFCIIfSIyr110N CIH $SNGI:
<br /> ']'his fo on should be, a,r ip,et_ „ ..r::k-the D TI II't I PLICA I"or the LOCAL AGF4N(,Y UNDERGROUND TANK
<br /> t
<br /> 3. Please tvrbc or print esu�ri4,�1� t to a.'.�'-:�G..� mfg rnn tiara, _.
<br /> , Use a hard Point you are ,€tar!eg,3 copies;
<br /> "ISP OF F'OR ;'MARK ONIN ONE,CT'AM'
<br /> L Mark an(%C)In the box next In the rimy that lac st describes the reason the forilr is being completed,
<br /> . Indicate the I)II.Ia or I tic's€ity name where the tank is installcicl,
<br /> A. irela€afi a:s €e€ t€,tt.: ltd� ft at4e:, _#anl €,s..r,€: €Ir3 f i tas�€k by fire cr�re s #t�ie9;ratti4y 11r J:aark{ex.<�E� iJ'8� .
<br /> B. Indicate,the;name of ftc cotn a.,y hac Manu atwo.,d the tank (ex. AC?' ETANK MFG,).
<br /> %. Indicate the year the tank—was, insa,lied (ex, 1987).
<br /> I3. Indicate the tank capacity in piltons €ex.25c )fl or 10,00()etc.).
<br /> It. TANK COMITWIN
<br /> A, 1,It MOTOR VEIIICLIAIJFL,a hect-,box 1 and cosrplet€.ite res 11& C.
<br /> 2, If nal MOTCI `:i'ilif'1 13 11LT ,J-,,,� ilic- plat€ofsr aae tray,n section A and complete itea2ra 11 I).
<br /> . Check the appropriate box.
<br /> C. Check the type of MOTOR V1`1111C'11FLJI°,I,(i3 box I is checked in ti).
<br /> TI. Print the chemical name:of the hazardous substance stored in the tank and the (,.AES. . (Chemical Abstract Service
<br /> number); if box I is "sII E"cite kcd in A
<br /> 11L TANK CODS UCaOON-MARK ONE YkT'', ftftf�, IN IIt 3)I'A,B,C:&I)
<br /> 1. Check only one oen, in, s .r ",i '. 'r. ,=..,t,TAc,,K M I"i RI L, INTIT IOR LINING and CORROSION IRItO"I'ESC,IION,
<br /> 2, If OT111°£2,print in the a c pr >d.
<br /> IVPIPING INFORMNVION
<br /> S. Circle A if above ground-1 6rc e U of aaerderggr.;tsn4 and circle-Beath if applicWe.
<br /> 2. If UNKNO N,rircl-:; €>r if O'1'I1[.,R,I.int ist spztee prrsvided,
<br /> 3. Indicate the LEAK'DI.T.I;C-FIO N slste€ifs)used to comply with the monitoring requirement for the piping.
<br /> V. TANK 1JAK DHIIN7110N
<br /> 1, Indicate the I-FAK c",cii in comply with the mountoring requirements for the tank.
<br /> ". INFORMIVITON ONTANK 1liWMII N.,iRIX CLOSET)I PDN
<br /> 1, FS-11MATED f)ATF I S:I U,, 1�D-ft.ONTII/YF R(January, 1988 or 01/88),
<br /> 2. " remaining in the tank(in Gallons).
<br /> 3. WASTANKfiIt,LI;I) 'I'1"a1C,heck 'NO'
<br /> APPJJCANr MU5r SIGN AND IIS°I"II,I�I,III S )IC A'171 ,
<br /> 19'I UCLIO Ir t.'I"III;LOGALAGENC DIES
<br /> \,"Te statunci ground storage e tai;;, dent fie *Mira sss.mbe is composed of the two digit county number,the three digit jurisdiction
<br /> number,the-six digit facility m nib.r and ,hc—,,�ix digit ,.,.s_ number. `be county and jurisdiction numbers are predetermined and
<br /> carr be obtained bI calling, the Si3te 11€r.rea (91f,)7' h facility number must he the same as shown in form "A". 'Phe
<br /> tank number may be assignee by thelocal at Etc'; <E�v�,� €,this number must-1 a numerical and cannot contain an alphabet. If
<br /> the]deet a envy prefers tt.a xis t Isf.a.P :€r .,n ,fin t?,,, e uk.nranal�er,please !Dave it blank,
<br /> I.I.IS T7111 RESPONSIBILITY
<br /> OW-11111, TNSP1X7 '17lE FAC~IUl'Y°I`C3 VERIFYTHE
<br /> r`�twC`. I C)I�`I`lf?Ilxilxd:tIxla),I`II::Ifsi, If Its I..CIC`JtI:.P��CIIriC Ii IZI�I*t� ;iillt:ls 13 'I9I C'C)tI�.II`C} (3I�'II:=;
<br /> *LOGAL AGEWYUSE ONLY'INIrOR Ia°fl"ON 11CI AND ITC)IC FORWARDING ONE FORM'A'AND SSOCII .IT'D
<br /> FORM-IR(s)-11)-1111z,FOLLOWING A I)I rl FyZi,
<br /> S`
<br /> WIT,'OF
<br /> SIS;"II' W ° , II ffIAR ES't X I° IICI 13
<br /> c/o!.fir.1? ,Ps,
<br /> t'.fl.IiC)X>r
<br /> prk mom= I N r A wan
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