COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

Home Browse Search

1N91'RUC'i10Ia FOR nOM I HI INCI I14W 6ENEI AL INi '±CUION'S: 1. One FORM "l3" shall be completed for each hank for kill NF.". HRM dig PPRMff CHANGES, RPMOVAI.S and/or any other TAN I r() MA:I°IC) I CHANGE 2. This form should be completed by cither the PER. 1'1` PI_dCANIF or the LOCAL L, A I , UNDERGROUND TANK 3. Please type or print clearly all requested information. 4: Use a hard paint waiting„ instrument, you are making 3 copies. TOP OF FORM, 'MARK ONEY ONE F11M 1. Mark an (X) €n thebox next,t6 the hent that best describes the reason the form is being compictcd. 2. indicate the. DBA or Facility name where the tank is installed, I. TANK DESC121 11ON _ C) PI 1a :L. I nws - IF UNKNOWN -SOSPIffIFY A. Indicate ouhiers' taaak11) # - If there is a. tank number that is used by the owner to identify the tank (ex_ A!370789). I3. Indicate the name of the company that manufactured the tank (ex_ AC:I E''AAN MPG,): C. Indicate the year the tank was installed (ex. I987). I). Indicate the tan;- capacity in gallons (ex. r�, t or 10,000 etc.). A. L If`NIC)'I'€)R VFIIICLE ITUEL, check box I and complcte items B & C,'. 1 If not MOTOR V1,111C'LE UE, check the appropriate box in section A and complete items B & D. B. Check the appropriate box, . C. Check the type of ;t OJ'L)fk VEI IT I l- I'UEL (if box I is checked in A). Print the chemical name of the hazardous substance stored in the tank and the C°..A,S. . (Chemical Abstract Service number), if box 1 is NOTchecked in A. III. 'IANK 0N9r UC'I'ICi - MARK ONE r11W ONLY d BOX A, B, c & 1) 1. Check only one item ira'I'"tPE OF SYSTEM, TANK SIr`t°FERIAL, IN"LEI IOR LINING and CORROSION PItti"iT;€'rION. 2. If C)"['HEIC, print in the spare provided, 1. Circle A if above ground; circle rI if underground, and circle both if applicable, 2. If t.;Ni NO%N'N, caa,lc: or if O'1111" , prilit in space pax,avided, 3. Indicate the LEAK 1111"C:` ON system(s) used to comply with the monitoring requirement for the pipin& V. TANK 11AK DVEEUDON 1. Indicate the LFAK DITYECOON systenr(s) used to comply xit a the monitoring re-g irenicrus for the tank. VL ININAMMnON ONTANK P1?,IL. , ANENIIAV C LaSEl) IN PLACE 1. I nS'I"IM FED I)NI I:•, LAST 1 SE'.) --M0 FlI f I: AR (January, 1988 or rJ"I J88). 2. F-S'TIi1 /VI'ED OUA I'I"i of IIAL'yRI)OUS fB91' NCS remaining; in the tank (in Gallons). 3. WAS',FIANC1111,11.D I'II IixiLil;"IM.NI` RIAL?Check'Y&or'N0'. r"al P11 r U I' SIGN AND I A'I' 'I I i? FORM AS I WNJIU). IMSTRUCITON I I2 '1"I 3 I . )UAL A€ I C'II- The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the sit: dn6t: fracitity number and the six dhdt tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling( the: State Board (91.6)739-2421. ''he facility number must be the same as shown in form "°A". The tank number may be assigned, by the local agency; however, this number must be; numerical and cannot contain an alphabet. If the local agency prefers the State. Board to assign the tank number, please leave it blank." I iS `,11E ESL'ONSI1 UXI'Y 01-n-W LOCAL I^: €.'ILII' ° °I`O VEMII"'Y 11117 ACCURAUY F) r '1"I W, INFORMA710N. '11113 U)C AL AGENCY IS RESPONSIBLE ItOR11111 COMPIH1,70N OF11111 "L OC'AI.A AGE Y USIf ONLY' INFO N]FI AND IZOR R)RARDING ONE FORM W AND , C1I'l D