|
1N,VFRVC*11, >' 1 COMPIXIING 1
<br />1EN13 - ' L INS 1, IC1 ."°
<br />1, One FO °"11" shall be completed for each tank for all N13W PVJtWIf PERMYr C IIANG IA REMOVATIS and/or any
<br />other TANK INFORMAMON CIIANGV-
<br />1 This form should be completed by either the PERmrr APPLICANT' or the LOCAL AGENCY tJ E " t?) ND TAN
<br />IN SPE r
<br />3. Please type or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are making 3 copies
<br />pt
<br />TOP 01?'E R . ~ "MARK C) ONE rill -1k.,
<br />1. mark an (X) in the box next to the item that best describes the reason the farm is being completed
<br />2. Eradicate fttDBAI' y name where the tank is installed. to„”
<br />L 'TANK DlISCA3Il HJi' ,' I IE ALL TIEWS - HI UNKNOWN « SO SPF4311Yi
<br />A, Indicate owners tank ID # - 1f there is a tank number that is used by the owner to identify the tank (ex, AB70789).
<br />B. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG.):
<br />C:, Indicate the year the tank was installed (ex. 1987).
<br />11 Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc,)"'
<br />IL 'TANK C ONI I I15
<br />A, 1. If MC)TOR VEHIC313 FUEL, check. box 1 and complete items 13 & C,
<br />2. If not MOTOR VEHICLE, FUEL, check the appropriate box in section A and complete items iT D.
<br />EB. Check the appropriate -bgx.
<br />C. Check the type of MOT6u EHICLE, FUEL (if box 1 is checked in A),
<br />EJ, Print the chemical name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service
<br />number), if box l is NOT checked in A,
<br />III. TANK CONS UCo11O - MARK ONE 171. 0 NLY IN BOXA, It, C: & Y?
<br />1. Check only one item in TYPE OF S"Y SM,TANK ANK Iol,!!TERI.AL, INTERIOR IOR LINING and CORROSION i'RO TE . ON,
<br />2:If OTHER, print in the space provided.
<br />. PIPING INFORMXfION
<br />1. Circle A if above ground; circle U if underground; and circle both if applicable,
<br />1 If I~II!'TC.N'OWN, circle; or if OTHER, print in space: provided.
<br />Indicate the LEAK DEFEICTION system(s) ua d ted comply with the monitoring requirement for the piping.
<br />V. "THANK LEAK DBIEC11ION
<br />1. Indicate the LEAK L1UITX TIONT'' systcm(s) used to comply with the monitoring requirements for the tank,
<br />1. INFOR iA71C)N ON TANK P1q1WAN1W1LY CIAXSED IN PIACE
<br />E
<br />1. ESTIMAIED E)A'I'F I AS'T USED - MON] `II/YEAR (January, I'M or 01/88).
<br />2 ESTIMATED QU ANTrI'Y of HAZARDOUS SUB,13TANCE remaining in the tank (in Gallons).;
<br />3. WAS 'VANE( FILLED WITH INERT ;REAL? Check 'fides' or `NO'.
<br />.>�, rte,,
<br />t,.: > 175 C SirN D l),
<br />-nII! 1�i3It INDICATED.
<br />IN "1°I217CNION FOR 1717 LOCAL AG C IE
<br />The state underground' storage tank identification number is composed of the two digit county •number, the three digit jurisdictions
<br />number, the six digit facility number andifte.,six digit tank number. The county and jurisdiction numbers are predetermined and
<br />can be obtained by calling; the State Board (918)739-2421. The facility number must be the sante as slscswn in form "A", The
<br />tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an allihabet. If
<br />the local agency prefers the State Board rd tel assign the tank number, please leave it blank.
<br />.., . a
<br />I
<br />ACCURACY
<br />OF `17IE 1' .r � >T ON. `1'E L,C L AG
<br />I riNc� S RI&S l n t S B E °t�R l vI? 1*y "I l ." _(r „ t
<br />F °1"EiII 1,1;TiL9N C)ir `E"1
<br />COAL AGINCY USE ON .Y* INFORMATION BOX AND MR FORWARDING ONE FORM "A! AND &SS0CWrED
<br />VO '13"(s) 1'0 1Ili'FOLLOWING A D
<br />SIFA119XI'ER REFSOURC;E-1; C:C N'i' 0t , 1$C)A 1
<br />DKI''A PR " a SIN a C.1 ;1C
<br />PO. BOX SZ7
<br />PAR AX$..9b I!, (A 90723
<br />
|