COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

Home Browse Search

,grRCTC" ioNS ix)R compizriNG . Its i GENERAL INsrRucnoms- 1. One i"TANK OqR+I " 3" shall be completed for each tank for all NEW P ES, PIA ` T a GF a, EMOVA1 and/or any,, .9 other A INFORMA17ION C:°II.ANGF- 2. This form should be completed by zither the IaI?I Mr1' PE ICAN'1' or the T.DCAL AGFNCY. UNDERGROUND'I'ANK INSPEC 1, C)II. :1. Please type or print clearly all requested information. 4. Use at hated point mit€n in t pan stat, you are making 3 copies. TOP OF FORM: 'MARK ONLY ONE n'[ -,M- L :I "L Mark an .(X). in the box next to the item that Fest describes the reason the form is being completed: 2. Indicate the DIV.9rN.Facility name where the tank is installed. I. TANS: m.7 -s R noN � q ' I<InM ALL MS - IF . UNKNOWN - SO SI" .a 'IIS *+ A. Indicate owners task II) # - If there is a tank number that is used by the owner to identify the tank (ex. AI370789). B. Indicate the name of the company that manufactured the tank (ex. t CM < "I"AN MFG.), C. Indicate the year the tank was installed (ex. 1987). I7. Indicate the; tank capacity in gallons (tne, 25, or 10,0etc.). H. 'PANIC C'.C)NTIT,N'IS A. 1. If MOTOR VEHICLE FUEL, check box '1 and complete items I3 & C. 2. If not XCC3 k VEHICLE FUEL, check the appropriate box in section A and complete items B & I). 13. ` 6 btle tW gp&tt ihle box. C. Check the type of MOTOR VEHICLE Ii7HL (if boa. 1, is checked in A). D. Print the chemical naante of the hazardous substance stored in the tank and the C .A.S.#. (Chemical Abstract 4rvice number), if box 1. is NOT checked in A. III. TANK CONSTRUC7110N - MARK ONE Y1`FM ONLY IN ROXA, I3, C. & 1) 1. Check only one item m TYPE OF SYSTE3: , `i'ANK MtS,'I"ERIAL, INFERIOR LINING and CORROSION 3" C3` EC"I°t0N. 2, If OTHER, print in the space provided. . PIPING Ci 1 "n0N 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if 01I`IIER, print in space provided. 3. Indicate the LEAK DE;TE;C: t;ION system(s) used to comply with the monitoring requirement for the piping. V. T^NK LEAK 1 X.'IIC)N q 3. Indicate the. LEAK DF I'ECrION system(s) used to comply eoith fthe monitoring requirements for the tank. Vt. INFORMNIION ONTANK PERMANINMY CIMED IN PIAC E 1. ISH ATI', i DATE LAST USED-'\+if3:INT11-I/YEA (January, 1988 or {31/58). 2. I3 FI TI;I) QUANT" s' of EIAZ", IU)OUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK FILLUD W1711I INI,'J<1' .,VFF,RlAL? Check '"Yes' or 'NO', APPIICANr S°I' SIGN AND DATli 111E IDRM AS INDICAT , . IN IJC'I ON FOR 71111 LOCAL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number, The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (€716)734-242'.1. The facility number must be the same as shown iia„ %arm "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. PE isum RESPONSIBILITY OF `I'EIE LOCAL AGINCY 171KI'INSPECIN11111 FAC:II: I' I°C) VI IRIFY31111 ACCURACY OF 11117 LN170RMJV11ON. TIIE LOCAL AGENCY IS RESPONSIBLE pR nII:i COMP111II014 0Ir 11TE, "LOCAL AGENCY USE ONLY° INFORMA711ON BOX AND ISR FORWARDING ONE I II "A".AND AS,SC)CaIA°I."E D FO -W(s) T0111E 111 laOLI NCI ADDRESS. NI'E? OF C.AI4I NIA C/o &W.E? Ii I1.Se P.O. BOX 527 PA UNI', A