|
y'ait1Mf T711 c FORM lir
<br /> E aw be complcmd Av each a;aa.,, y_.t all NI Iy PF' L1As PUMNITY'C 11 NOUS, 1 I.. I VATS and/o„ any
<br /> '"o `r.aN C.1IANGU
<br /> Ess amTkod byeithcr I,CILAL AGIN(N I1NI)Is'IYC:a1IOUND`l'A1'C
<br /> .INSa DOR,
<br /> C 1-he a T..rd puhit wrifingi'Tsitarnent,you are;nay ,ng 3 copic,
<br /> ":1 OP C`f,1'a RM: 'MARK CIiS'1.eY 01SI,f'IVM'
<br /> z. Marr(an Q) in the box iraxt to the hent that test describes the reason tine fcarrlt is being cxsrnpietcd.
<br /> 2. fr=day m.we DRO,or I aiwihty to mm,There the tank is instrilied"
<br /> 1. IadNK III SC;1CIIY;f;'I1T -('()M"L,1?P1 ',ALL I''I:1¢. -117 UNKNOWN -SO SPUCIFY
<br /> e,-n rs MA ID 1i°Mere is a tank number that is used by the owner to identify tire tank(ex.A 7t078Q.
<br /> 11 ..,,T, mu the name of the company that manufactured the tank (ex.A('MF'"f%°CNK MFG,).
<br /> CI 7
<br /> : ,et�3;e ha year apY'L tank aa�a�anstrali<x+l {ex. 138J).
<br /> it bWocate t€,r uwk capacity €r gillons (ex,25,00(9 or 10)0()()ew),
<br /> IL TANK
<br /> A. 1. 1< NIEiIUlk VITIUC,TI?1611.check ti.,x"I arel cannlaiscte slcrats R & C:.
<br /> Z If ,,c NRYFOR TUTTt,TG€[,aii.,>Beck the appmjmkoe xs,�r rn s:c.tiaz>?A air;complete ftems 33 Az D,
<br /> B. Mat, b "frig r hm,
<br /> ,r a R VKHRIUS s t i r t ` =e 1 Q t rmcke f is A),
<br /> s,, a ni the ch i, ..r. i,_=me it Me h) aWm;, sklawy xt3md in Me faink and be('.A,S. ,(chemical Abstract Service
<br /> 111 TANK a,',OYN°9113tj('t'fON- MARK ON[i OTM ONLY IN 1O1.) A, 11,N&1)
<br /> L Check on,one i,anr A"INPE!Oil SY @ Fcd,'L s,,`'K MATF IAL, I ITERIOR LINING and (.',01C OSION k'BOTT('1`IC?W
<br /> i. If 01111 fkk pont in the space providcdl
<br /> TV. PIPING UNMURNIM11ON
<br /> C irc i A if a In"w,grouraait circle U if a peas rgror ntb and circle bath if applicable,,
<br /> ' , r, E
<br /> If € '�r,.�<?s-_, ,°a°1. �3, if E_TI2f�ut f..,�t in iab rnici d.
<br /> .3. Ir,ris ate Me Ll,.,d14, s,y.atc:at y)card trYevanply with thatmonitoring requirement for the pipiatg.
<br /> V. Tikoil
<br /> fi ciica.. tax 1.z A I i,d r,C:.:1=CyS a atenufs) used to ccarnoy MA the niondoring requirements for the tank.
<br /> V1, IAI a a 11.3 1,. Iii LANK,PIi a ANI7N"I1 ( OSlj',y'I IN PLACWIi
<br /> I, I'<IFINIA`LID GATT. LAST USIt y- MON-111/YF Ganualy, 1988 or 01/88),
<br /> ai ' 3_nI I11'�1) QUAS a' of .t�°�l�TtfTC1US SU It � t�C I're�attainiarl in ttYc tank {ars Gallons),
<br /> 3. WAS TANK 1111,10 WI T`IC 'Y,,s'ca `NXY,
<br /> APPLICAP117 AMUS S'IG is AND 1':Tdd"T'I;111F,PORM AS INDKAUTD,
<br /> 1N51T1rJ t iiBl FOR'1111% AC HN01 t°
<br /> I a state ne"arground _arae g'>' tank identification gr:m1ber is coni�pciccd of the two digit county number, the Ame W&jurisdhion
<br /> number, Me six digit .Ua t number and the six digit tank number, Ile county and jutisdhairaa numbers are predetelmined and
<br /> can be cit ht ed by selling Mq `latc Board t} f3j r a QL IN iacRy number must he the same as shown in form"A'. Ile
<br /> tmk number may be a,`a4n t by the Imal of sEcyr hove vc-r,this number ntaast he numerical and cannot contain an alphataeL If
<br /> e1,.-local agemy pe,MXs We Tme.b,<3ta to s .,.ti'a?.�k,. we.LnC-ralsb, please leave it IPIfil3lae
<br /> tf rS I°II1x R1M 1I1ONS113iSIT Oil SIB!1AXIA h a.,r" C 5 'I TAI"IIS ISI:C I I11Ix IrAO rI'S''110 VUR117y'11111
<br /> A(-'(:t,,'RACY Of `11HE Ii aI=C)ITMA'I"OAL 1111i 1,tt(i/xL A 11s".NOY IS 11="N*'I"CITaSIBIA-,FOR 11111 C:)MIT1I 1°1C) I OP'111F
<br /> t,CCCAL AGIN OLYk I,1Sf,ONLY'INIrCTRkA 1IC tPC BOX AND FOR ItORWARDING C NU,ICOR *A* I)A." Tl:'lMMI)
<br /> y,)RM R'esj TO"OU,,,P01.1.,1) INN A.I3f RUISSS.
<br /> S"1"'y IV WoCI ';R RPSO'111aIFS(70N' Ctlh BOARD
<br /> CIO warp's.
<br /> rp's.,
<br /> DATA f5iIaCI13i&SlaN(;(.'1: n?,R
<br /> PXX BOX 577
<br /> PAI,~Afr OUN'l', r 3 '
<br />
|