COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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CIC 11t)NS FOR COMPLITFING A'Ir GENERAL IN' 'R1 CHONESs L One FORM"B" shall be completed for each tank for all N , �Ei "1S, I?Rl rr C.IFAN S, RPMO AIS and/or any other' AN INlk)R 'I1t7N(S ANG 2, 'I'his form should be completedby either the PFRmrr APPLICAW or the LOCAL AGFNCY I:IND ERGRO YND'1ANR VISI" -10k 1 Please type or print clearly all requested information. 4, Use a hard point writing instrument,you are making Yeo sics. L Mark air(X)in the box next to the hent ihat best describes the reason the form is being completed, 2. Indicate the DBA or Facility marc where the tank is installer, I. 'PANIC DESC;RII�F"ON-C()MPI-Fj'F AUT,THIS-117 UNKNOWN-So SPIX IF Y A. Indicate yawners tank 11)# -If there is a tank number that is used by the owner to identify the tank(ex.AB70789)� B. Indicate the name of the company that manufactured the lark(ex,AC.\4E 'I'AN MFG,),C. Indicate the year the tank was installed(ex E987), E). Indicate-the tank capacity its galleins(ex.25,000-or:10,WO ctc,). I[, TANK CON 1'W I S A. L If M01'O VEHICLE FUEL,check box I and complete items}:I& C:. .EP not MCS"I"t7I2 t`E;IIIC,I,E,I�"'UFL,check the appropriate box in section land complete items II �& D. F3: Check the appropriatc box. C. Check the type of MC;i°E'O VT'''IIIH I, 1 I I.EL(if box 1 is checked in A) I',' Print the chemical name of the haratcous substance stored in the tank and the CA,S,#,(Chemical Abstract Service number),if box 1 is !,01,,'checked in A. Iiia 'TANK C✓ON9r1ZUCa TON--MARK ONE OEM ONLY IN BOX A,B,C&D I. Check-only one item in'rYPE3 01"SYS1.`F 5,'l'ANEC MA'I`E'RIAL, INTERIOR JANINCI and.CORROSION PROTECTION TION 2, If OTHER,print in the space provided. IV. PIPING INMRMATION 1. Circle A if above ground,circle U if underground;and circle both if applicable. 2, If UNKNOWN,circle; or if 0'111ERI print in space provided, 3. Indicate the LEAK DI°,'I I:C."! ON syrstcmt s) used to comply w th the monitoring requirement for the pigin.-. VF IANI-EAK n'I X71ION 1. Indicate the LEA I) S Ii€.7iIE)N s sfern(s) used to complywith the monitoring requirements for the tank. Vt. INFO A°I1ON ON'TANK I'ERMANEN I I (71,SSI I1 IN PLACE 1. 1511MNTED DA'FF I.,AST USED-MON'rll/YE?AII (January, 1988 or 01/88). 2. Es-rim vi`t;