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Oxy r°I:AMptJ' y `( kyr r tr
<br /> C,;,"sI;RAL I? S'f`Ixl,CFI iC)NS:
<br /> (:7sT.., FOR 04 < .haU be .; ..plated E`kv sun t"k Her Cib NEW PERMYI'S,I FRA4 I'C'}3t1t G1P`S, I1Ia, 1:IVT-S and/or any
<br /> odC,t "Ire,NIN1r%)1CMa'11CyN Ct IANGE
<br /> Z This t..:z. Aould has rE,nTbr d by cith;r the Ply, `I' Isla I"or the ", .AGENCY TLJ,N"I:IUI2GROUND TN
<br /> If SPI X A b'R,
<br /> ,a
<br /> q. the at hwd Ia,.rs1'Wrr10% ai t tillc'a,y0ir are,unaking_a copse,.
<br /> "„r, ",a
<br /> v11�Cya ?a,�II. n, ��j r„ 1�j°°�L"I' 3°� 1,t 2 I2a�1
<br /> t, ?alar, . . Q in the Imy pew , the Hein tMI Fest describes be reason the form is€aes"iig;completed.
<br /> y. 3,ndrr,( Is 1'sBA kart Why wave where the tank is iriscallcci.
<br /> 1, AN I7I .1:;I ,(a � IS-1XF&,uI.Yt R!C ALL r[It S s IF UNKNOWN"-SO SPECIFY
<br /> v indway, k. ,n n aim ID 0 .. 1f'Mew 1s a tmk number that is used by the c wnsr to identify the tank(ex, AB741789).
<br /> .,, t_. mp,os< ha rasa”;faaa.tsso� `t.e irsnk fez,1'�C?4II;'I`t VK nT.C.i,).
<br /> x. aw ' the yearUse tank Ass rr t alter"a Q, 198-,'..
<br /> 11 InUate we �aara.. rat aaeiay in gallons tox,25.,00 or 10,000 etc,).
<br /> II,. TANK C.II 1 a"I;1
<br /> 1. if,v)' Ia1Z r'ly.zf1 ,t.l Ftwt,1.,C1neck1Cox I and crinipletre items 11& C.
<br /> 11t no_ MUI`OR VF11ITIE i iT. ciock the sappr,,wiatc bsir in section A and complete sterns TI & D,
<br /> CA _, WI alt, (if hc'x 1 is stressed in A),
<br /> 1:1, Print tho chun sk a,.n r3. . of the havarAnts.,r"ta,,ar r„ slaamd in the tank arld the CARR Chemieal Abstract Sm6ce
<br /> I. C:hsa k .Q one hem in"zNPE .1a y .h,.::s,"l :nt MA`t 31'i IAL, IN-rT,.RTO F LINING and CORROSION PFU)T`T°a£,"IJO .
<br /> I1 Ea€1 :>z1. print in '� ,y.'e .(.viCle"J'
<br /> IV. PIPII91 IN1rC3Ita:e't.`I:"Ii.N ,.
<br /> 1. cird <"",tf rlirrr's ground circle 'C if=a a rdr€ourid;and circle weir if applicable.
<br /> 1 if l aux 00SI'aa, ,€rcleor sf(,a 1 r H,R, fir,gr in spare provided,
<br /> y. hwhodu me L' ",.Kt.C1lON spomYl s..d to mmply uiid The monitoring requirement for in( piping.
<br /> V.
<br /> _. 1sWkWL Me LA Aa?1 T used to winp,Win the mrsnittrrmg requirententi;for the tank.
<br /> V1, x1'411 RIP"AA1,017 eT°"4. r.?.&p�.�'S,tS�>�.�F���.,°A`�E.,�� A =.a",1";111,IN PLACE,
<br /> . 1T1r.1,. fJ) DATE .rbS1" a `,d:DC -cJ, aan 1'1a1"YTFAR (January,1988 or 01/88)
<br /> a. 1y>y, N ,MA)1_,UA, i< "V a," IIAZA€1T1131?S k. a T.1TM<''1 rennalning,in the tank(in Gallons).
<br /> 3. WAS'JANK FlIXED yyr'I'u I.al,RT MA'FFI1IAU? C;'heck'Yeg' or'141Y,
<br /> s
<br /> .I�I�I,ICAbT`I'MU,SI ';:,a1 DIx IT,,771FI=0111 ;`tS.as:�1St'1"AST'31
<br /> a
<br /> 1N-',SF I1.1r,1,1r7 1 yt I"" .LO(a%J.AG12FIES
<br /> Its sale and rly a.on a marage Wk iden,;tikat"a n nw&er is cotI7I%C}sed €f the INvo digit county number,the three digit jurisdiction
<br /> ;, I ilsc ,�f_�1 tea, s gri' a a. ,,.1 as. ,sa=. .,rx zit f,:i task Raaan.ber. 'Pae county and jurisdiction nunsisers are predetermined and
<br /> can r:' o 3, aaa :g, €hna�41(91N7342421- !'he fadlit'y number nimt be the same as shown in form"A". The
<br /> tank aa,.aatsua .aaa 3,modg a ,_7 "1.e kn al _,s,nq; t o e at r,Mis number must be numerical and cannot contain an alphabet. If
<br /> die los"al as zcy prefen', the We !bard to anipi Ne .a th;r uminner,phase leave 1t lalank_
<br /> I"I'IS 1111011 1,.>SPONSIBILU O T 1I'I.1ICAL AGENC Y'11INI' SPIX'I,S``I1 ?I?A('I I"1'TO iiiXIFY 17111
<br /> , .CA ('Y IIIc 11I1 IN1 ORMA 1'1f:)N, '1711'LOCAL AGENCY IS RESPONSIIII:E?IkWITIE('C)MPLE,110 OF'111
<br /> "DO<CzAL Cx1�':«ggC Y USE fa} IN''pJNFC()1 td°yI`a0N I AND I YR I NONRINIQ C)IVI:'s Int) WAND 'iE�C 'ITUD
<br /> FORM*fr( ",I�K� 1���.:�F �CLl,f-,'t',Y"}3if K3'
<br /> Y a,.1'a ATF,OF ITU 1i'1'a T.ra
<br /> SIe1 'Ix N1'ilt ES(I C S C',O 'I` 01,BOARD
<br /> x 0 1Ya."e T EP""2.
<br /> } 1}liia I IAri1°I.`,�da. §l'f1..ia }..AAW11
<br /> 19)X SP
<br /> (A 947-23
<br />
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