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HNSCRUCLIONS 1`1011 COMP111 if
<br /> I, One I"`C'3R- T"shall be completed for a._,°l= rank Ifor all ", PI"'IRM1703,PERMTr CHANG I, EMOV and/or any
<br /> otherTANK INFORMN]IONC'atAi..;i'.
<br /> 2. This forin should lac completed by eithc, €ie C3 « fAGENCY UNDERGROUND TAN
<br /> 1 please type or print dearly all requested
<br /> 4. Use a hard point writing instrument you, are making 3 copies,
<br /> 'FOP OF . "MARK ONLY ONE TI'E w
<br /> 1. Mark an(X)in the box next to the item That best describes the reason the form is being completed
<br /> 2. Indicate the DBA or Facility name whcrc the tank is instaflc',d"
<br /> I, TANK DE S w IFI"IC -a)MPLUIE ALL rIEMS..Ila UNKNOWN-SO SIlix1fry
<br /> Indicate ovwttzets tank FI)# -If there; is r, !arik number than is used by the owner to identify the tank(ex.AB70759).
<br /> 1I. Indicate the name of the company that .aa?nufac cured the tank(cv.AC F `I"A"v
<br /> C. Indicate the year the tank was installed (ex" 19n.
<br /> I). Indicate the tank capacity in gallons(ax "5.t or 1t1,{'. ctc).
<br /> 11. TANK CONIENDS
<br /> A. 1, If STC.),"i(M VEHICLE LE FUEL,check box'l and complete items 1I C.
<br /> 2, If not dl`I`OR VEIIICsl,t?FUEL,check the appropriate box in section A and complete itenta Fl & D.
<br /> B. Check the appropriate box,
<br /> C. Check the type of MCJ'I'OR VEHIC 11i 1'`UEL(if box I is checked in ).
<br /> D. Print the chemical name of the hazardous substance stewed in the tants and the'C;.A.S. .(C'herilwal Abstn',tet Service
<br /> number),if box 1'is NO 1"checked in A,
<br /> Ill, TANK C;C) 1` l,latyl1 ) -MARK.ONE MiM ONLY IN BOX A,I3,';Cp& )
<br /> 1. Check only one item in TYPE,OF SYSI°EM,"p1 NIK MAIT.RIAL,INrITRIOR LINING and CORROSION IsRO'1`7C VIC) .
<br /> 2. If 0'1711131;,print in the space provided,
<br /> IV. PIPING INK)RMNITON
<br /> 1. Circle A if above ground;circle U if underground; and circle Beath if applicable.
<br /> If UNKNOWN,circle;or if C)111ER,print in space provided
<br /> 3. :Indicate the LEAK DESA ECl'I0N system(s)used to comply faith the monitoring requirement for the piping.
<br /> V. TANK LFAK D13FIRNION
<br /> 1. Indicate the 1.1AK I)F lTC;I'lON aystern(s),used to comply with the monitoring requirements for the tank.
<br /> VL 1 H)IC n0 C 1�'1" IC.Isla II I 01)SI?N3 IN IsI. C:11
<br /> 1. F;S`IimAn.i)II `I.I'i I SI Ci I I"t-�att)Is"1"I1/ Ft (January, 1988 or fltf5 ).
<br /> 2, Ian C°I a1'IED QUAN11kt'"Y of I1AZApi OUS SUBSTANCE remaining in thetank(in Gallons)
<br /> WAS TANK I'ti.sLED WITH [NEXT' A'I'FRCIAI,? Check 'Yes'or WO%
<br /> 1sPLICA r MUSTSIGN AND I)NE"li'1111f 1k)RM AS 1 1)C "E"I 1),
<br /> 1N 'I UCtIO I 1 '1111:LOCAL AGT1 0I!S
<br /> The Matte underground storage tank identification number is composed of the two digit courity number, the three digit jurisdiction
<br /> number, the six digit facility number and the six digit tarsi;number. Tbe county and jurisdiction numbers are predeterminedand
<br /> can be obtained by calling the Mate Board (910)/.1e1-242:1. I"tae facility number must.be the same as shows in form "A", The
<br /> tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local ascucy prefers the Stwe Board to assign the tank number,please leave it blank,
<br /> 1"[°I "l 111 S1�C) T5I11 Tl" C)Ig'Cll t I C)C 1< tll; I°11a I"I C 1�s"1III 1'AC�l1 1 "1'C VI"bltlf�°1 11;
<br /> AWAACY 017 17111 I MRMKI ON. 1111I:I C)C' Ia+AGENCY IS RII-SK)PISIBIE1 "E"111'1 C OMPI I`1110 OF 111H
<br /> *I C) A AGENCY USE!ONLY"INI E"1C7 )ESR t"RWARt)I G C) 1 MRM*A"AND ASSO ° °I"Itl)
<br /> FORM -W(s)7X)*1111E V011,0WIN(I ADDRILSS.
<br /> ,grAIE WAIER Ft X)CI12CIL4 C'C)MIVOL BOARJ)
<br /> C/o ss.. ,lm.P.S.
<br /> DATA PROCESSING CENJER
<br /> P.O.13O 527
<br /> P OU I',C. 90713
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