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<br /> ,N',ARUCKTONSFORC MIS
<br /> GFM�RAL IMSFRUCITONS-
<br /> I One shall be compicted for each tank for all NEV PERMTIN,PERMTr CIV,�NGF_S, RF,IMOV3_
<br /> '
<br /> mr the PERM.Tr APP LJCANT or the":AL AGENCY UNDERGROUNDTANK,
<br /> ct'�-11 cleart,v all requested information.
<br /> I rn gJnst rumen t'you are rnakiqg 3 copies.,
<br /> 0
<br /> 1. Mark a, the next to the item that best describes the reason the form is being completed.
<br /> 2, J,_,Uity name where the tank is installed.
<br /> rI17MS SSpIx "
<br /> A. ImL, YAers tank [1) If thcr�is a tank number that is used by the owner to identify the tank (ex.A137,0789)"
<br /> B. Indicate the name of the company tUt ipanufacturt, -mk(ex.ACME.TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1.987),
<br /> D. Indicate the tank capacity in gallons (ex,25,000 or
<br /> 5,
<br /> A. I. If MO' 1,,,R VEHICIT F1 K.1,check box I and complete items B &C.
<br /> 2. If not ,`,OTOR VFIIKAIFU.El..,check the appropriate box in section A and complete items B& D.
<br /> B. Check the appropriate: i- ,
<br /> C. Check the tSpe of NW, F FUEL(if box I is checked in A).
<br /> D. Print the chemical s,;odous substance stored in the tank and the C.A.S.#. (Chemical Abstract Scvice
<br /> number),if box I is NOT I in A.
<br /> ,T, TIT M ONLY IN 13OX 11, 13,C&D
<br /> 1. Check only one item in'!:J W SYSIT-1*TM,TANK MATFRIA1,WFEMOR LINING and CORROSION PROTE('11-10N.
<br /> 2. If OTTIER,print in the space provided.
<br /> TV. ;N' �AATION
<br /> 1. A if above ground;circle U if underground, and circle both if applicable,
<br /> 1 If UNKNOWN,circle; or if OTHER,print in space provided.
<br /> 3. lnd«atc tlh(, T_F/\K DE7F,C1ION ,v
<br /> stern(s)used to comply with the monitoring requirement for the piping.
<br /> OW 700"
<br /> L Indicate thc LEAK DI"TI.H.C110IN sys1cm(s)used to comply with the monitoring requirements for the tank.
<br /> VI. 1,.,"t ;,N V/,,iNNK PURfirs NEN.11M CU)SED IIN PIACT,
<br /> 1. USFINI,, LWIE L, TUSED- MONTII/YeAR(January, 1988 or 01/88).
<br /> 2. ESTINT ).:., a t s, of IIA/ARDOUS SUBS`I',`iNCE remaining in the tank(in Gallons).
<br /> INERT MA'IFRIAL? Check'Yes'or WO'.
<br /> 3. WAS'i �"J f,T� ' I
<br /> AND —1,143K,"A A'S,INDI(WIED.
<br /> 'N,
<br /> �;I'RUCFION 11OK1
<br /> The state undergiound storage tank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board(;16)739-2421. The facility number must be the "me is shown in form "A". The
<br /> tank number may be assigned by the local agenjy, however,this number must be numerical anO
<br /> ,Wannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> Tr ISUIF RRSPONSWIIX'Y 011110", !,0(VkL AGENCY IIIAT MWE)CIN THE ITACILTI'YTO ')?E
<br /> ACCURAC*Y OF 7111F I4I tSI�n,S =1 '. l wlTQ(W,.A(;17N(-Y IS RESPONSIDIP.FORUll"CC-14,V;1IF�."A 01"'ITiP,
<br /> SU 0\ PX1 X AND FOR FORWARDING ONU*FO "j
<br /> 1,0CAL AGENCY U, 1�Y' �_NP)F%4 I W D
<br /> 9FA'1 CA
<br /> XX,527
<br /> '90723
<br />
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