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I <br />;NSI°I1 AJ 11 NS FOR COMPIJUING'T "II" <br />1. One FOR "Ii" shall be completed for each tank for all NEW PI:3 " « , PI3 it (31ANGEA RIWOVALS and/or any <br />other TANK ZION (31 G& <br />2. This form should be completed by either the PIIRwr APPLI(YiNF or the LOCAL AGENCY 7 ERC*9U `"I` N <br />TNSPa , <br />3, Please type or print clearly all requested information. <br />4. Use a hard point writing instrument, you am making 3 copies. <br />TOP OF It 'MARK ONLY ONEa6V <br />1, ;Mark an ()0 in the box hest to the item that test describes the reason the form is being completed, <br />2. Indicate thi Dity name where the tank is installed. <br />I. TANK ISI �N - `$ IJSIB A11, r1r.. S - W UNKNOWN - SO SPFAMIY <br />A. Indicate owners tank IIS If there is,a tank number that is used by the- -t identify the tank (ex. AB70789). <br />I3, Indicate the name of the company that manufactured the tank (ex. ACME TANKMFG.). <br />C. Indicate the year the tank was installed (ex. 1987). <br />I). Indicate the tank rapacity in gallons (ex. 25,000or 10000 <br />II. TANK C(7N"I'13N"I�5 <br />A, 1. If WXFOR VEHICLE I UEI,, check. box 1 and complete items B & C;. <br />2, If not MOTOR VEHICLE FUEL, , check the appropriate box in section A and complete items B & D, <br />B3 Check the appropri° &Iax. g�� <br />C. Check the t of` OT671-VEFIICLE, EL (if box I is checked in A). <br />13. 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 />91, TANK C'CJNS"J' 1:i(e11ON - MARK ONE TIFM ONLY TIOX A, 13, C; & D <br />1. Check only one item in TYPE OF SYS .,%I. 'I°tkNKiMATI:,- IAI,,, INTERIOR LINING and (:CtI2ROSION i'It%ITE IION. <br />2, If OTHER, print in the space provided,, <br />I ".'IPING)r INFORMNITON <br />1. Circle A if above ground; circle LJ if underground; and circle both if appicable. <br />2. If UNKNOWN, circle; or if OTHER, print in space provided. <br />3. Indicate the LEAK DETEICTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DEITA-11ON <br />1. Indicate the LEAK L3 u 3 71ON systems) used to comply with the monitoring requirements for the tank.: <br />1, INIX)RMATION ON TANK PI ;WANIWILY CI Si313 IN P C; I <br />1, I"rS MA'I D L7 "I i Ilii i1SED _ ON FII/5'T'AR (January, 1988 or Ol J ). <br />2. I`>911M iTED QUAN]IITY of .I-IttZAItDOUS SUBSTANCE remaining in the: tank (in Gallons). <br />3. WAS "TONIC FILLED W171711 INERT ' I✓II.IAL? Check 'Yes' or 'NO'. <br />ArVfJf4AJq,MU6r SltKAND DNI -E UIE FORM AS T DicNr Ia. <br />"I'he state underground storage tante identification number is composed of the two digit county number, the three digit jurisdiction <br />number, the six digit facility number and fe,s* digit tank number. The county and jurisdiction numbers are predetermined and <br />can be obtained by calling the State Board ( )739-2421. The facility number must be the same as shown in foram "t1". The <br />tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br />the Decal agency prefers the State. Board to assign the tank number, please lemc it blank. <br />.r is nm RmpoNmurry oF linj x I 'I IKI' INSPI PI'S °1'111: FACILm TO VFMIYt <br />ACC 11 C OF TIE INFORMK11ON, ITIE LOCAL AGENCY IS RRSPONSIBLE FOR 113I27 (3OMPLIqT0N C) 11113 <br />*LOCAL AGENCY USF ONLY" RIMRMATION BOX AND ISR FORWARDING ONE FOR "A! AND"SOC ` 11D <br />FO W(s) TO 11113 FOIAOWING ADDRESS._ <br />�STMIII&•s`.... ` t <br />c/0S.WY-F-P.S. <br />gP.O. BOX <br />gq y5g27 c <br />