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GENERAL 1N,1;FRIJC'J10Ny,-.
<br /> 1. One FORM "I?" shard be completed f'or cacti tank `t r al NIyW til Mr.I ,PI1R:m.rr CHAN ,.'„S, RUMO :I.S and/or any
<br /> other'EANK INFORMA110N CHANG171
<br /> 2. This form should be completed by either the 1"118 1' I' T' NS`or the LOCAL d GEbld.,Y UNDE GROU D T i
<br /> INSPEr-170k
<br /> 3: }'lease tyke or print ctcar]y all r;,r'luestcd 3[zfaa•tr4<`ation.
<br /> 4. Use a;card point writing instrument,you ars: making 3 cop:cs.
<br /> TOP OF R)RM, "MARK ONLY ONE,I'llim'
<br /> 1. y4a:rk an(X)in the box next to the item that beat describes the reason the form is bein,a con -xtcd.
<br /> 2, Indicate the DBA or Facility ratune where the tank is instalfcd.
<br /> L TANK DIISCRII"'I'IO --C OMPIZIE, 1.1,T11 S-IF UNKNOWN-SC)%PI `FY
<br /> . Indicate owners tank 11) #-If there is as tank number that is used by the owner to adcrrs 3y t€a Lank(ex,x113'70789).
<br /> 3. Indicate the name of the company that manufactured the €ank (ex.ACM 1,,NNK Ott(;t.),
<br /> C. Indicate.the year, the tank was installed(ex. 1,987),
<br /> I). Indicate the: tank capacity in gallons(ex. 25,00)or 10,000 etc.).
<br /> IL TANK£".C) I`I1S'6S
<br /> A. 1, If MOTOR'a1L 13IC,Lti FUEL,cheek box'f and complete items 13&C;.
<br /> , If not MG)"S`OR VEHICLE L t L 1',1,,check tare appropriate box in section A a::d complete is aa, I2.arc T),
<br /> 1). Crock the appropriate box.
<br /> C. Check the type of MOTOR V1.411C:L,1% MILL(if box f is checked in fs).
<br /> 13. Print the:chenucal narne of the hazardous substance stored it thm tank end the C, S. _, (C"hcrn ,,al Abstract S rAce;
<br /> number),if box 1 is N T checked in A.
<br /> III. TANK C.O NS11£LIC7170 S v MARK ONE TITONLY IN BOX A,14C& D
<br /> 1. Check only one €tern in TYPE' OF S Y`i 11,LI, .<• K MA11'RIAL.; 1°C1'I 1IIOR(:,ENING and C .at1,K)rSION P1,1,0 1"C;"t'1ON,
<br /> 2. If ttTlilIt grit=t in the spacr,yrovtdcd,
<br /> 1. Circle A if above ground; circle 19 if underground; and curie hc)th if applicable,
<br /> 2. If UNKNOWN,circle:, or if 0111HR,print in space provided.
<br /> 3, Indicate the 7,I 3(La1rE C I'I€ s stems) used to comply wh1i the. monitoringCz;r{air rstert fr._° the piping,
<br /> V. TANK IXAK l)IAI`=(N ICL
<br /> 1, Indicate the LFAK L3t.1i('l1ON system(s)used uo compiv with th€ monitor'mg resi€blrcrrez < r ,h: tank.
<br /> VI. INI'CII rVIION ONTANK t'ERMANI_tMI7,Y C ,£)SF'D IN PTAC`I
<br /> L ES11MA1 "sI)19A'11"LAST US11)-110"(T11J `L°AR(ta uaaty, 1€88 or 01/88).
<br /> 2 E'S'I"1MI NTED()UUVN'"1 FY of 1€AZ iFZD01,1S SL L1a1"I'ANC 13 remaining in the tank.(in (lallons).
<br /> 3. WAS TANK FILI,IC,I3 WITH Vg1f2i,Me,'U,,RJ yL'1 Check' 'es'or'N(Y,
<br /> XP11 ' 'MU SIGN AND DA-11,711P FORM AS INDIC KI :1;1.
<br /> TIbT.Ssl`I2U( 1`ON TUR 7TIE LOCAL z1 CA-„NCI1_-S
<br /> The state underground storage tank identifici6on nur ber is,composed of the tm,,,)digit;county nunrlbcr;the three digit jurisdiction
<br /> nunsbe , the sax digit facility number and the Six digit Lank trturtbctr The co'unly anel jurisdiction, n rs.hers,are pr deetennined and
<br /> can be obtained by ballinl=,the ;State Board (1)16)730-2,1111- 'Lire f cOitt r umber nest be the sannc a: ,w-n in torn "A`, The
<br /> tank number may bc:assi d by the its .1 agency; hoc a,, r, this murnber must Inc muntercal ano cvmr,,.! e€nta.nan alphabet. If
<br /> the local agency prefers the. State Bord i::r assigli the tarok 3 aaniber,please leave it blank,
<br /> A S'17111 1C1`s I"()l'S1BUX17 OF'IIIE 1X3C I, CLI C TI "I”t mIs1 T II1'L11I?hAkT ,I°I" I -)VF,R1T`Y,I11f1
<br /> ACCURACY OF 17 1:,INF OICt 'I'ON, 1111i LOCAL AGE, Y IS RESPONSIBLE FOR11111 C OMPL1I110 01VITII?
<br /> '11)CAT,AGINCY USE ONLY'I K)II I. ,T ICI I BOX AND FOR FORWARDING ONE I )R 'A'AND t) )C "1VD
<br /> 1 ) "11-(s)TO 17HE 17H1'f)LLO I CL t DIkEN&
<br /> SlINIT 70B IZES[,A.i C V,'5(X) I°K01,BOARD
<br /> C/o& nP,S
<br /> 11/x''!4 PR0(J�&qNG CltN`I1'
<br /> P.0—BOX 527
<br /> ISA' £'UNI',Cad fr)MI3
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