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<br /> INS-F�..p&,.3,x9tn�a�RFi Rao AFOR�..A.A£XgkA Ll UINGi �6..Y
<br /> GEN
<br /> 1. One s t RNl "B”shelf be cornpic tot for each tank for<ll NEW PURMrrS, Ir U CTI CI? , IC1iMOVAI S and/or any
<br /> other NK III ?IC 1r1I`ON C° IA NG
<br /> 2. This forst should be completed by either the PERM E° PP C:, "or the LWAL AGENCY UNDERGROUNDTANK
<br /> T °,SIz.C1'4'1 ,'..ti
<br /> i3, I°lac ram or print clearly, 11 requested information,
<br /> h=adppwa
<br /> cgrrsunre j?; y eopi
<br /> 'IOP OF INARM:W ARK.ON ONLY ONU,TI.
<br /> Mars n (X)hvift°tbo ee'A to ttre item that Ucst describ s this reason the for
<br /> st2 ft�ei �,c<>Qaaflcte<f.
<br /> i
<br /> 2: Indicate the DBA or facility gime where the tank is installed,
<br /> in TANK DF-SC1°IPI1ON-C OMPI.,F Ila ALL rums-IF UNKNOWN-fit)ISPEX11N
<br /> , lnd car€e, owners t<auk"ID#-If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> ta. 1,late the nine of the:company that manufactured the tank(ca.ACME"IANK Mr—c").
<br /> t . Indicate the year the tank was installed (ex. '1987).
<br /> D. indicate the tankcapaeny in gallons(ex,25,000 or PfOW etc,).
<br /> I. TANK C:( k':pla, I:C
<br /> L If MOTOR VEHICLE.Fcif"L,,check box I and complete hems B& C.
<br /> 1 If not IvtC)'L"OR V17II1CLE"FUI`Ja,check the appropriate box in section A and complete items LI& 1).
<br /> £3, Check the appropriate box.
<br /> C::. Check-the twp� of :�It�'I OR VF,1llCt, : IS FUEL(if box 'l is checked in A),
<br /> I7.
<br /> print the chemical name of the hazardous substance stored in The tank and the C,A.S. .(Chemical Abstract Service
<br /> number),if box I is NOT checked in A,
<br /> HL TANK C ONSIRIXTITON-MARK ONE'rPEW ONLY IN IiC3 Ai,I3,C&I3
<br /> I. Check only one hent in TYPE OFSYSTEM,TANK fr TI:s121t L, IN l..,'ZIOR LINING and CORROSION II'RO'ITC"I10N.
<br /> .a. If 04111lIZ,print in the space provided,
<br /> I'lC PIPING INErC`RMN 1C:Il
<br /> 1, Circle A if above ground; circle L.3 if undeargroundl and circle both if appl€tabic.
<br /> 1 If UNKNOWN,circle; or if 011JUR,print in space,provided.
<br /> 3. Indicate the LEAK F,—_11C"I'10N sy-stem(s) used to comply with the monitoring requirement for file piping.
<br /> V. TANK I:I�=,Ar EPEC` tltd
<br /> I. Irdscat,r the LEA h)f.111 1`ICy y tc rs,s1 used to comply with the monitoring requirements for the tank
<br /> L INFOltMA-17ON ON TANK L URMAf;Ar"1 IVI C LO St i:t IN PIAC11
<br /> .. Lsn'%lAIED D.,y F LYV; °USED- OIN I/YLAp (January, 1988 or 01/88).
<br /> L,S I�I�x'f'I_:I f3L?twe I I'I of IIt,:1 llL:dflt,, dYlf "L'r tsc;I:f.ru <airain in the tank(in Gallons).
<br /> 1. WASTANK I L,LEID WITH INI_,1'R °MA'I ,RIAL7 ("heck 'x'es'-or'NO',
<br /> A I1I.IC:I,O'MUS1'IiX;N AND IWI"II"1IF P()RM AS INDICIVIUD,
<br /> INS-1'RIJcnON FOR 71111 LOCAL CL3? C."ES
<br /> The same underground sto g1sr Wak ,«e n6fic.aflon nuants r.is composed of the two digit county number, the three digit jurisdiction
<br /> ar sn r, tlrr:sir shigh Pa_alsy numb,cr ansa the rix digit tank number, The county and jurisdiction numbers are predetermined and
<br /> „ tt be obtained by calling the State Board' (9V,)739-2421, ':I"he facility naanrber must be the same ars shogun in farm "A'. The
<br /> L:, k rnn lhcr Play he assigned by the local ar ce cy, however, this number must be numerical and cannot contain an alphabet, If
<br /> ml, b m the;'.t.,iti;Loa rd to t,.a.?n lret ieunk number,please leave it blank.
<br /> IT IS 17II.11Ii:LII°C NSF1I1L,1"1 s.F°1`1111 LOCAU,AG1]'NCg '11I T LaNSP C YS um F CIII,I I `M E I2 E'Y 1111I
<br /> a CClt:PLAC :OF111F 11II[W)RMA110N, '1`111"s LOCAL AGENCY IS i?E-SPON STBLU,ROR 111E C:C? I'I.I ION OF 71
<br /> 11100AL GE C YSE'O k)RM V 1ON BOX D FOR MRWARDING ONE FORM*V AND AW:)GA711iD
<br /> IURM,W(s)T01111?FOLLOWING ADDRU&S,
<br /> C/O W.1iJf.I,.
<br /> 1JUA PROCLSSING CHIN11MR
<br /> P.O.BOX 527
<br />
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