|
W
<br />INfs`I UC'I°IC)1' S FOR .". ., °I Cs f ) 'fly
<br />Caft,NMlAa.
<br />a 1 l B h all be completed for each tank -`sir aH ; PE � , I�11 VITT' CCA CLL ES, REM(` AT S attd/or� ar,y
<br />he a�� I f FF A 1ICl 3
<br />This ,c„s„ she uld be completed by either the PE.RMrI' A3'PJJ A ° car the LOCAL AGENCY 3 INIDER'r1f OUN `I'A
<br />3, Ple<se, ce or s;nt Clearly all requested fnforlint6 n,
<br />4. Use aha€d point amring instrument, you are making 3 cs;api s.
<br />1, Mark an ()) it, the box next to the iters that best describes the reason the form is being completed,
<br />n. Indicate the I,111A or Facility Dearne where the tastk is installe(L
<br />L W%NK DESC 1.IMON - C O LI f 3 All, f f'E S -IF UNKNOWN ®SC3 SPEC” II1
<br />A� lndicalca o,,,v aers tank 11) # - If there is a tank number that is used by the owner to identify the tank (cx. AI3707,89).
<br />fl, Indicatt, the rsattte of the company Haat manufactured the tank; (ex. ACIME TANK FG.`.
<br />C. Indicate the year the tank was installed (ex. 1987),
<br />D. indicate the tank capacity in gallons (ex. 2.5,000 or 10,Cky) etc,)..',
<br />11. TANK Mi 'I`f3% S
<br />t%. 1. If MOTOR VEHICLE FUEL, check beef and cc nipletc hems B & C:,
<br />2. If not MOTOR VE1{I( LE, FUEL, check the appropriate 11)t?x, in section A and complete itentu,13 A i).
<br />B. Check the appropriate box.
<br />C:.'. Check Ills type of SfC)"t"OR W".111C,LE 3 Cal l., (if box i is checked in A),
<br />D, Print the eltcrrical name of the hazardous substancestored in the tank and the (',A,Ss. . (Chemical Abstract Service
<br />number), it box I is NOT checked in A.
<br />111. TANK CXY ,' . UC) ION ONE HIM ONLY IN BOX A, f3, C'
<br />1. Check only one iterni in TYPE OF S'O'S'[ Fa,K TANK MATERIAL INTITIRIOR LINING and CORROSION 1'fZe7TEX7 10 ',
<br />2. If C3'1HEsit, print in the spaceprovided.
<br />IK PIPING WFORM-201ON
<br />1. Circle A ifabove ground; circle L! if underground, andcircleks th if applicable.
<br />1 1C U s °`dO N, circle; or if O'IIIFIZ. Eeriest in space provided,
<br />1 Indicate the LFAK I)rq C"I'ION systurn(s) used to corrislr wifb the rronitc>ring requirement for the piping,
<br />TANK I LEAK DFfTff,"1' O
<br />1, Indicate the LEAK ri'6'L;MIGN system(s) used to comply with the monitoring requirements for the tank -
<br />VL INFORMA110N ONTANK PERMANEMILY E1AMSE `9 IN PLACE
<br />E
<br />1. ESI` MA-17ED D,,VII? LAST US11) - I0;N7I1J/YIk ft (January, 1998 or 01/88),
<br />2, E,'"IIMYVIED OUAN1IITY of IIAl..tkftl)C" US -ST 1;xTtVACL' remaining in the tank. (inGallons),
<br />3$ WA. I t K 1`II,I,ED WI"I'll I'~a1i✓RT NIA"Irl TRIAL? (::heck 'Yes' ter 'NO'.
<br />I `Cf'f1I)C"I ON, FOR 711E LOCAL AGENCIES
<br />I'he state underground storage tank identification number is composed of flat too digit county number, the Barre digit jurisdiction
<br />rumb,cr, the six divit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br />call be obtained by calling the State Board (916)73 9-2421, The facility number must be the same as shown in form 'A', 'I le
<br />tank number stay be assigned by the local agency; however, this number crust be aaaanterical'and cannotcontain an alphabet. If
<br />the is cal agc,,ncy prefers the State fioard to assign the tank number, please leave it blank,
<br />1'I IS'IHE RENPONSIBILMY OF 1111 ,)CAI,A °si? ., `IIIA I` fe34l C i 17111IxAC'I cry `m izizu' r of
<br />ACCURACY OP 'IM felfadRMA170N. 'I` IE FOC"AI.. ACIf'.Nty`Y IS PJ,aSKWSI13i,141' IAC? 111F3 C:C) i"I.:I"I'ION (01,17111"
<br />'LOCAL AGE' USE ONLY* INIX)IC ]ION 13M AND FOR FORWARDING ONE FO 'A' AN13 AS.SC)C: tk" ED
<br />FORM ;'I3 as) 0:1�) I`fIE FOLIDWING AF DRI— S.
<br />yo
<br />GIVEN PROCESSING CENTER
<br />P.On 13OX 527
<br />
|