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INS'M C'PION (C)MPL.I'"I'FNG Iia 'I
<br /> Gf..1 7111CAL lNM'RUCI10NSe
<br /> 1. One I a.ITLN41 I1 hal,isc a m a-Ecl 10",each tank f,"Ir all N1tW PfIRMI'17,3,1 FRMrE(:11ANGnS, RfaCiVAIJS and/or are
<br /> other`PANIC 11S )1IMANNC"):In CII.ANCt1C
<br /> 1 This fora,should be c on.,.la to I by cidl r the, PF'IItr1CF AMIT IC N or the LOCAL E C 1 t 1)ITIRGR UND TANK
<br /> 3. Please type or ptfiat clearly,all
<br /> d, Use a hard point-,,sr f=., ,,d,Fr,aa,� .�1;-r r are making;3 col-nes,
<br /> TOP Cllr I )I . 'MARS ONLY C) 1:11TI,
<br /> 1. Mark an ( in the bus next to the;terra that best describes the reason the form is being completed.
<br /> 2. Indicate the IBA or hasciiity name where the tank is installed.
<br /> 1, TANK CSI� Rt t) -C:t:} Pt..f,t"'ALL t V;MIS-IFUINKNOWN- )SPMC
<br /> A. Indicate owners lank It) # w If there is as tank n-umber that is assed by the owner to identity the tank (ex.AB70789).
<br /> II, Indicate the:narrsc the company la a` atanufactcred the; ran), (cx.ACMF,TANK FG.).
<br /> C. Indicate.the year the, tank was inslaflcd (ex, 198-7).
<br /> D. Indicate the tank c apac}r( it, galicans(era.25,(#y)or 10 000,t.tc).
<br /> II e TAN (:C)pfpI:Sl l'11
<br /> A. 1, If N1 T 1I r Ij.I1Ia.a I,1 II_I.,ch-,A bwas_l area complete de°rays B& C:.
<br /> 2, of no, MOTOR 1 1110.';FUTT,0 .t, 'he 9 noprinte. bcix in section A and complete items 11&D1
<br /> R. Check the appropriate box,
<br /> C.', Check the type:of_N40 OR p a .11(1.1, l f Fi,(if box "f is checked in A):
<br /> , Print the cheinical n mt n the b. andl..,,'saoslance stored in the tank and the C.A.S. .(Chemical Abstract Service
<br /> number), if box I is NOT t cite_'.c c in A-
<br /> 111. TAN C C)NI tsCTION- MARK 0,V r 11:t ONLY)N 19,)X A,B,C:&1)
<br /> 1. Check only ove rte„n in .,F "MINI ",4AT RTAL,1INT TUOR 11NINCr and CORROSION pllt 3TT`X,7t0N;
<br /> 2, If C)'T`IICI print in the
<br /> IV. PIPING INFORMA7110N
<br /> 1. Circle A if above ground„circle U if unclerg oundn and circle both if applicable.
<br /> 2. if UNKNOWN, circle;„or if OTIIFIR,print in space provided,
<br /> 3. Indicate the LE:?A pil, TC"I O b se-,,tern,,,)used to comply with the monitoring requirement for the pipittlg.
<br /> V. TANK 11�AK.DF111,710N
<br /> L Indicate the I.I°AR l la,i I C7110N -,dete ah” used to comply with the monitoring requirements for the tank,
<br /> VI. Ila FO M VI`1CII C)1 TAN PF'RMAIaII;I II. (1,081,T)IN PLA(l1
<br /> L LSPINIAAITI) I)r5:1"I?,LAST CSI,T)-MC hs 111/'STAR(January, 1988 or 11]./38).
<br /> 2. res 1°4 iku., QUAN FrIX of IIA j\RD(JSU t1y` a N('1' remaining in the tank.(in Gallons),
<br /> 3. WAS'1A K FILLI✓I) WI'lId INL.TIT MAIIaIIaAL? Check 'Yes'or'NO',
<br /> APP11C.ANF Pd1C3sSr SIGN AND DiVIII1711i MRM AS I� 1)ICNNITID.
<br /> INS 6'RU(`11ON FORTUE 1 C'AL AGENC IIIS
<br /> ']'he state uncierLRuaanrl storage tan ria,`=_ ,at:cs=artst.,l,wr is ea ul
<br /> posed of the two digit county number,the three digit jurisdiction
<br /> ' cumber, the ox dam€ fact_ axumbc= aaml ifs,,rK digit mnk nunibe r, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by afling air,, S,w B(-,o� i � ,'t a.a tlr";. )'he facility number must be the same is shown in form ret"A". The
<br /> tank number may Ise assqned by t re, _,F of; - a y;bias �ver,t=is number must be nxrrz erical are cannot contain an alphabet. If
<br /> the foul agency prefers the State t,o a,sign thc tank number,please leave it blank..
<br /> `1'IS'1711!RUSPC)?SITI11,`1" (A-1111F,LOCAL fCAL :a CNC '1'1 AI`T SP IC.I °" 1z FAC.'ILrl' TO MITI' '11111
<br /> ACCI.i : '-Y )1x'1'1 1t' )RMA'I°ICI . IIIA LOQU,ACIIr. C Y IS .r O SI T,LI FO '11 F COMPLIETION OF1111i
<br /> *LOCAL ACei1 (7`USFONLY*INFORMN110N BO iAUND 17OR FORWARDING ON1 ICOR *A'A 13 ASSOCINIUD
<br /> IX) -IP(s)alb)°1211;FOLI,t) ING rel"IIaRI!,&I.
<br /> R1'A`I It OF CAC 11) RJIlaS
<br /> S I A I CI al A 111'. BOARD
<br /> C/O SaIt,I 11.ro,
<br /> 11A'I'rs. -
<br /> PCk BOX 577
<br /> RA.RASCC)LezNI',C.,'I ..
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