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<br /> C,1;'siURAt,ifV"""1 ttUC,12>DNS,:
<br /> Onc I c,31f.I1 11" shall be completed f€>;c each tank for all NEW Int`? 'MI'VS, I URAMI"I'C".ItAN(1IsS, 1C1IPaIdWAII;.5 and/or any
<br /> 2.. Thie t . n, sfrauld be Completed by cittier the RF I'APPLICANFor the I:.C?(', L AGENCY UNDILIRGROUND TA,
<br /> dS1r1 C I)
<br /> 3Pkeiisa itpe, or 1aYaw:clearly ail requested inforiclafinn.
<br /> Use ea haa'd point writing a,listrunicni, You are making 3 copies.
<br /> TOP C:I13 FORK W ,.x:' I:tAII.N' C.tNU I'lTi "
<br /> s, 'Mark r �X) iaa the tacaslnbxt iii the ,tem that best describes tate reason the form is being completed,
<br /> 1 lndica , ...<; DBA or Facility namie where the tanks installed.
<br /> I, TANK DHSCPI„a,a -C;OhI; E AH,nems-I.F UNKNOWN-SO SPIXIFY
<br /> A. Indica%, owners tank fiat - If there is a tank nc niter that is used by the owner to identify the tank(ex.AB70789),
<br /> B hldt cat%: ac nVin.ic,^ of the (""onq)way th armaataafiactured the tank(ex.I'rC°:yC'C;TANK FC").
<br /> C, Indicatc. 1ic year the taank xab arist�ailed (ex, 1987).
<br /> D, Nidi aac the tail;c=tpacitlr in pt,iltons(ex.25,M)or 0,iyN}etc.).
<br /> IL TANK COMENV'i,
<br /> I. If ytf"'?`OR t"Ie)l:ICL F-UlFI.. ch ck talar I and complete items II & C°,
<br /> 2, If n€,, MOTOR R y E111 'k, , z ?..;.1.,c hci k th. appropriate box in section A and complete items 13 I7,
<br /> 13, Cbeck i- appropri'MI",
<br /> C". (' aE c k ,:°,c,lype of yIt 3,e_ap .I UHICi 1,"',,I>1,(€'box `_, is checked in A).
<br /> ', 11HUv c, chl .ii.c,I iia w )f ghee ",Om,,..€c s .orcd in the lank and the(.,A,S,#. (Chemical Abstract Serr%ice
<br /> It>. T;IONX, INAMRK ONE lf, fm, a ,'yN.1° 'IN Th()X A, 13,I"&I)
<br /> C h ca. TYPIF", . .. SYS`F!. ',M, t,a,vK MA ER.1<A „ IN7rFiRIOR IJNI°G and CORROSION F'It OTFX'31ON,
<br /> C�3� f .ai] €_. .
<br /> ,. I:f 0 P 1 �?I 1,1,a,ina in £ Bovis ed,
<br /> r, Circle A if above groamda cat"cle 1)if an,�Ia rdround;and circle both of applicable.
<br /> 2. If UNK",J)'VeN,circle,or if OTHER,I lint in space provided,
<br /> 3, bidicat, the LEAK D11I IX-1€0 sylt nt(.,y ;ae.d to conipl=wrnh the monitoring requ€rernen€ for the.pipinlg.
<br /> TA-NK LEAK IST 'I;t 1„1Ca„,I
<br /> 1, 1aa€taco.(,Die LF—AK 1.It1I iF`'t ION sy-le,i(:) use,; to comilly with the monitoring requirements For thc, tarok.
<br /> VI, 1NI°°C3al:MA11014 ?6 TANY 711„TMA!1 5"I'l;Y C LOST;a IN PLACE
<br /> E
<br /> Is 1 ID _ 1I tof;I -m af1I, ,f,4 ;.{Iaaua , 1 ficarply« ).
<br /> 2, e=py t IA.'.=1,.. C,UA`` J."t'of t t,oaeAkZa:e('af`'y>aLtalsl'ANa�tk re.rasainirt,in the tank(in Gallons).
<br /> 1, WAS,, ;K IFULED i :l rl i „ia1.al a l,."Iltrla ' Check'Y cs' or IN'0'.
<br /> PPLIC AM, 7151 SIGN ANT)DA'171 17111,FORM AS 1NDR IED,
<br /> R,4S'FRU('O(`aN IOR :»1a"1,CsI'".,4L.6,1,Ai.H€
<br /> .?c. .>ra.e st a,aa..ns 1"h he ac,o:, ,i,.nn.a r e,composcA orthe viva digit county number,the three digit jurisdiction '
<br /> m cr.ine a gig Fzuml.r and fC c digil 1,ank nuribcr, The countyand jurisdiet�ion numbers are predetermined and
<br /> . .
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<br /> e;e<„ ,.€ a 1 e a,;i, ,.,� ..ta,e 1,,tc�f[ f'a6,'t7,39-242 The facility number must kis the earns as shown in form "tS". Zlte
<br /> in .,..i.b . ;.�;a t, ..c.;i °bs t F..raj ry7 ha v c-ver,this number must be numerical and cannot contain an alphabet. If
<br /> t'i =acaa 1 . r:a caa_,,. t,a, 1.0._:: to ,nc ::a 2k number, please leave it blaaak.
<br /> n 1S xfuii t T,-SPtala`111jLH 1a 0111THE LOCAL,.1a F C'IIM 11 0 VERIFY 111E
<br /> AC'C'UR C ,' i1'a1a I"III":IN3'`ORMI I10 . 1111*1,00M,A(;[,',N(.'Y JS RESPONSIBLE 1aOR 111?C OMPI.IiT'ON C:F 177 m
<br /> 'LOCAL ACs"
<br /> frI*�iC.Y ONE,,ONLY'AIial'Ca:lt7Il,aa`711CaN M- AND MR FORWARDING ONE: MRM W AND ASSOCINIM
<br /> t,1tilA ly M 1t1E'1aC.1„k",CIICVI.lti r1Datfata;S&
<br /> sii 17?WXIVR II.1"SI1aU C;1 S Cs1:aN1'ROL BOARD
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<br /> .t'.,_AlE.:�{�PROW,!,�S}'Y3l.L z 3..3 `3 te e ...
<br /> 1 �a B E(fn
<br /> pAis A1i7 Its, TI,('Yk I
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