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04, <br /> ENS ONS FOR MP CY FORM"? <br /> GENERAL SI°Ri3 TCI e <br /> 1. One FO "BI shall be completed for each tank for allE< I PERMrf CI ` Cams, R1:? OVAI a and/or any <br /> other TANK INFORMATION CI IANGP- <br /> 2. This form should be completed by either the PEMMIT I P ® "or the IX)CAL AGENCY UNDERGROUND TANK <br /> ..� INSPR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,yEiagt.mtcopses;,, <br /> TOP CII " . ONLY ONE ITEW <br /> 1. Mark an(X) in the b peat to the item that best describes the reason the forms is being completed <br /> 2 Indicate the DBA or Ficility name where the tank is installed. <br /> I TANK DO . 6k-a 1.1E .r AIS Dims_ a t _so spurivy <br /> A. Indicate owners tank ID#a If there is a task number that is used by the owner to identify the tank(ex. 70789). <br /> E3. Indicate the name of the company that manufactured the tank(ex~ACME TANKMFG.). <br /> C. Indicate the year the tank was installed(ex.1987) <br /> D. Indicate the'tatrk capacity in gallons(ex.25,000 or 10,000 etc.). <br /> IL TANK C01,1M.W17S <br /> A. 1. If IVIC3'IOR VEHICLE FUEL,L,check box I and complete items I3&C. <br /> 2. If not 141C7TOR VEHICLE FUEL,check tate appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VE✓IRCLE f UFL(if box l is checked in A). <br /> I7. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. .(Chemical Abstract S'e"itice <br /> number),if box E is NOT checked in A. <br /> II1a TANK CCENRUC:II[O -MARK ONE nEm oNim IN WX A,1:3,C&I) <br /> 7.. Check only one item in TYPE OF SYSIENC TANk"°MATE ItkL IN-1`E RIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV PIPING INFORMA11ON <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle: or if OTHER,print in space provided. <br /> 3. Indicate the LEAK EST' .`E ON system(s)used...tcomply with the monitor.ng requirement for the piping. <br /> V. TANK LEAK DUFF-ClION <br /> 1. Indicatethe LEAK 7E T[ ON system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATIOINI ON TANK PENENMY CLOSED IN PLACE <br /> E <br /> 1. ESI1MATED DATE I.AS`E'USED-MON"I:'EI/YEAR(January, 1.988 or 01/88)- <br /> 2. ESTIMATED CUA '111 of I-tfirAIZDOCIS SUBSTANCE remaining in the-tank'(in Gallons). <br /> 3. WAS TANK F,II.,I.ED WrI711 INE;Irl'"IZIAL?Check'Yes'or WO'. <br /> APPLICAM'MUST SIGNAND D I7I TIIE FORM AS INDIC° I ; <br /> INSI'RUCIION POR."IIIE?WCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction <br /> number,the six digit facility number and the six digit tank number. ne county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State E3oard ()16)739-2421. The facility number roast be the same as shown in form "A". 'Me <br /> tank number may be assigned by the local agency, however,this number mist be numerical and cannot contains an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> FI'Intl mm y o "nm wcAL AGENCY niAT I sPE crs Ti FAA E? 'IIID <br /> ACCURACY d OIT'IIII1 INFORMATIOM IIIE LOCAL AGE C`Y IS RESPONSIBLE FOR 11113 CC1 . 13?'I"IO OF'nIE <br /> 'I L AGENCY USE ONLY'UVORMA17ION BOXD FOR I RWARDING,ONE FORM W AND ASSOCIA1131) <br /> R "(s)TO°IIID FO11,E I G ADDRE <br /> /O S WJ P.S. <br /> II I'. PR '1?NS NG CIWITiR <br /> P.O.IX)X 527 <br /> Ria , <br />