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INSTRUCTIONS FOR C.,ML. t �1, �.._
<br /> GENERAL -1 NS Ri.1C 1 =.'.iw3:
<br /> ;r.. t,:r 'l NEW PERMITS, PERMIT CHANGES,`REMOVALS and/or any
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<br /> (., °PERMIT APPLICANT or, the LOCAL AGENCY UNDERGROUND TANK
<br /> F,
<br /> NSPE.FTO1.
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<br /> 4 U1s{. a t,air i ,,;, t'�`, w .t,," nsc r um;or you are f��f3k i n, 3 copies
<br /> TOP OF FORM: 'MARK ONLY ONE ITEM,
<br /> I Marr an (XR r the t>c),� nf,sx? ,,) t h(,, ,em i hat best d ss^ri bes the reason the form is being completed.
<br /> Ifim('atf? ��' roEtC:r' t,��r. tar-1k, instal led,
<br /> T . TANK DESCRIrIION COMPLETE AaL ITEMS a IF UNKNOWN - SO SPECIFY
<br /> r T.�ttat: `it : .,f{�. by tit' owner tfIC�E,'Ylf,1fY't.k?d? frank
<br /> i r t h, a°?k- t ex A Mr TANK MF
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<br /> Il . TANK CONTENTS
<br /> t)()x 1rl:}:. c,iC"r;t F tt, 1 teC15 B C,
<br /> .,. ? ? F r?fc.i thio ;7,>r,<,t� box rr section A and complete items D" D.
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<br /> r„ •,,? ;r ug ,r HI c U r
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<br /> :, {,nrri.k t?r:+ .,E � �. M„i ��.. A?,l (. � U!+ i . kuix,;l is (,,.i7c�CkE'd 'in A).
<br /> 1? Print the i;'17('tr?cis 1 f;iali., 17t t"he i?tl%trdow1� shored in the tank tinct the C.A.S:#. "(Chemical
<br /> At),,,', i'..t. �r�r v I(., nij!,:E)r.:' , 'Y,i N01 cPlfii'kPd ;M A.
<br /> III . TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C & D
<br /> i! ,Y ;r. ty M, i I1r :;P; 1rcRtiar Fc)cyr`.::>lo TE,?)lr.ric)tw
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<br /> IV, PIPING INFORMATION
<br /> Ci r cl r "A i f a at o g c>ur c. rcl e E undergrounul, and:ci rc i o both if applicable.
<br /> 2. IF-UNKNOWN circle. or if Orar ;, in,5,} c, :provided
<br /> 5 I,r;d,r. .,fr
<br /> . _W ..� N I-Li, 'iUN Y..'. ' .$) used la comply w?h the monitlorring requirement for the piping.
<br /> Vo TANK LEAK DETECTION
<br /> Ilnd,cate the-4 1.frAK JETEC"1,3N syst2 ?ts) used to comply with the monitoring requirements for the tank.
<br /> VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
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<br /> t \ a!C''l r'Ci !C he 'tarty (i n Gallons)
<br /> _� +^,yC ria __ U t'ai i' .�1.�.; t'71.7t_ i ,. ,+. `l
<br /> APPLICANTMUSTSIGN AND DATE THE FORM AS' INDICATED. '
<br /> INSTRUCTION FOR THE LOCAL. AGENCIES
<br /> 1 ie s ., and ° rou .i i,i'v t"zc'. i{ i f <<fi, r++a,F'Y is Ct ?lpt.sed of the two dgit county number, the three
<br /> C t, E'a C7 "rl } .d ;E.� , ." s X d q,t -sacs l i ty number �1G-t�'le 5?X -( lt�i t
<br /> tank Yl drt yet . The county and
<br /> ,)wr s ,cl �r,? r.?nDet< ,°e;;,r :et err i ne ay,
<br /> car be b a i r , av e State Board {516) 227-4303_ c
<br /> ' � _ c � e,� t calling the he
<br /> facr' .,y rt; i,^, tlh Sar:
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