WPC\ ؓƶN [iPxqzϵ27"ЁTg2,%38.d^D#Huu' R5BymF|x/j=wcѥг2H@~xzzp643j }+R?;1yJ\7!#ryՏ۝R]GwәOk-O,ђPH&Y|ٰɝ{19ى0!?QK w  *djAIRil)x~@˺gf4vd#'|niY" R\Z/f;beu|@_ݴVt뛲xj;cAvCF58i Ux0wI,< wwJAu ']& Cvwk, L'ae5# F UNQ % 0 w@C 4   m UM: f f f a f a f) f+ a- aA fU aW @Tk f f a a a f Es @T o W ?f@To [?!f #a #a# 03#f# B# D+ $ 0K7$$ D3H%{%a(a(f)(a+(o ?(?1f2a2a3@T3 0k3o %4?= A>fp?ar?f?a?@T?o ??IfJaJdJvLL BaL 0+cM AQhMM 0DN D/N BN D3O BBO D3_O D3O BO D3O BP D32P B*eP D3P B*P B-P DCQ 1m\Q 0wQ 0@R 0R 0jS 0T 0T 0U 1V 0L6WWHXY 1YN[Z 1]Z BBZ C &[ C@[ BCZ[ h[ h[ h$[ h$[ h[ h[ h[ h$\ h'\ h-\ h3\ h9\ h?\ h7E\ h|\ h$\ h\ h$\HP LaserJet 5/5MHPPCL5G,,,,0vL x9 Z6Times New Roman RegularX(vDq$,,,,XX )  ) ) HIDJKDLMDNODPQDx*%xp3|xQUcAZ"Arial Regular,,TABLE BsTABLE C TABLE DTABLE FhZTABLE E5E:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGMz=TABLE ATABLE GTABLE H E:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGMWPCssS3S351351$`hRhoh+&hh351`hh351`ohRh{3518` ObS{351 `G1Pp -Lk  #.8BMWb|z`D&$6EQkXOZCZ8[,[![[ [[[[[[\\\\\351\`[Y[k[_gurQ2351d`)6BNZf~3518` pkkppSSqpqp351`1 )E`z 5rL]bGh7oS8(9K}]ipV60`351`1Q2t\D-r]G~dN>h4715Ut3Kb(x9K]p+09`CKQ351`aoS8*B]y~sjc`a7eSjor{ 2D"TCahlbYuPkGc=\2X%US TW^fpzxmcZRtMhKZNKS=[0d$oz zoe]VRPRW]welnaxWMC8v-m"d^ YVVX\ahpy351H` /AQ`qy(1:BJ|Ru^dfTjCm2k hc]XSOJE?92FZn !5I]qomj gb1\DSXIk>~2%  {n$a'T*G-:/-123321/-+)&#xma VK8&~iT>)-BWk@@NE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGME:\Miscellaneous Files\Graphics\Logos\EPALOGO.CGM($E:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGMWPCssS3S351351$`hRhoh+&hh351`hh351`ohRh{3518` ObS{351 `G1Pp -Lk  #.8BMWb|z`D&$6EQkXOZCZ8[,[![[ [[[[[[\\\\\351\`[Y[k[_gurQ2351d`)6BNZf~3518` pkkppSSqpqp351`1 )E`z 5rL]bGh7oS8(9K}]ipV60`351`1Q2t\D-r]G~dN>h4715Ut3Kb(x9K]p+09`CKQ351`aoS8*B]y~sjc`a7eSjor{ 2D"TCahlbYuPkGc=\2X%US TW^fpzxmcZRtMhKZNKS=[0d$oz zoe]VRPRW]welnaxWMC8v-m"d^ YVVX\ahpy351H` /AQ`qy(1:BJ|Ru^dfTjCm2k hc]XSOJE?92FZn !5I]qomj gb1\DSXIk>~2%  {n$a'T*G-:/-123321/-+)&#xma VK8&~iT>)-BWk@#@NE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGME:\Miscellaneous Files\Graphics\Logos\EPALOGO.CGMoTABLE ITABLE J(3$ Dq!,,,X X$XXX X X$   d'dxd( $ Figure  1  Level 1Level 2Level 3Level 4Level 5++++'dxd  7. 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TABLE MTABLE KTABLE LWPCssS3S351351$`hRhoh+&hh351`hh351`ohRh{3518` ObS{351 `G1Pp -Lk  #.8BMWb|z`D&$6EQkXOZCZ8[,[![[ [[[[[[\\\\\351\`[Y[k[_gurQ2351d`)6BNZf~3518` pkkppSSqpqp351`1 )E`z 5rL]bGh7oS8(9K}]ipV60`351`1Q2t\D-r]G~dN>h4715Ut3Kb(x9K]p+09`CKQ351`aoS8*B]y~sjc`a7eSjor{ 2D"TCahlbYuPkGc=\2X%US TW^fpzxmcZRtMhKZNKS=[0d$oz zoe]VRPRW]welnaxWMC8v-m"d^ YVVX\ahpy351H` /AQ`qy(1:BJ|Ru^dfTjCm2k hc]XSOJE?92FZn !5I]qomj gb1\DSXIk>~2%  {n$a'T*G-:/-123321/-+)&#xma VK8&~iT>)-BWk@@NE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGME:\Miscellaneous Files\Graphics\Logos\EPALOGO.CGM=TABLE MTABLE N<E:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGM(3$ Dq!,,,X X$XXX X X$  WPCssS3S351351$`hRhoh+&hh351`hh351`ohRh{3518` ObS{351 `G1Pp -Lk  #.8BMWb|z`D&$6EQkXOZCZ8[,[![[ [[[[[[\\\\\351\`[Y[k[_gurQ2351d`)6BNZf~3518` pkkppSSqpqp351`1 )E`z 5rL]bGh7oS8(9K}]ipV60`351`1Q2t\D-r]G~dN>h4715Ut3Kb(x9K]p+09`CKQ351`aoS8*B]y~sjc`a7eSjor{ 2D"TCahlbYuPkGc=\2X%US TW^fpzxmcZRtMhKZNKS=[0d$oz zoe]VRPRW]welnaxWMC8v-m"d^ YVVX\ahpy351H` /AQ`qy(1:BJ|Ru^dfTjCm2k hc]XSOJE?92FZn !5I]qomj gb1\DSXIk>~2%  {n$a'T*G-:/-123321/-+)&#xma VK8&~iT>)-BWk@:@NE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGME:\Miscellaneous Files\Graphics\Logos\EPALOGO.CGM.)-, I&mage <=8C HKKKKsTABLE N=TABLE MDE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGMWPCssS3S351351$`hRhoh+&hh351`hh351`ohRh{3518` ObS{351 `G1Pp -Lk  #.8BMWb|z`D&$6EQkXOZCZ8[,[![[ [[[[[[\\\\\351\`[Y[k[_gurQ2351d`)6BNZf~3518` pkkppSSqpqp351`1 )E`z 5rL]bGh7oS8(9K}]ipV60`351`1Q2t\D-r]G~dN>h4715Ut3Kb(x9K]p+09`CKQ351`aoS8*B]y~sjc`a7eSjor{ 2D"TCahlbYuPkGc=\2X%US TW^fpzxmcZRtMhKZNKS=[0d$oz zoe]VRPRW]welnaxWMC8v-m"d^ YVVX\ahpy351H` /AQ`qy(1:BJ|Ru^dfTjCm2k hc]XSOJE?92FZn !5I]qomj gb1\DSXIk>~2%  {n$a'T*G-:/-123321/-+)&#xma VK8&~iT>)-BWk@C@NE:\MISCEL~1\GRAPHICS\LOGOS\EPALOGO.CGME:\Miscellaneous Files\Graphics\Logos\EPALOGO.CGMsTABLE N Z ;" X$XXX X X$  _     w  &#   wӐ#Ԉ   1    w  &#   w#  RCRACERCLA CFR CAS USTmineworking USTs   ]Gray MatE d <d d <d d(;3$2#  0  .3  0  N;)OPC<< CLevel 1Level 2Level 3Level 4Level 5($$   1  QQ' dxdP PdSSSS'dxd dQQQQ'dxdVVVV'dxd dXXXX'dxd dZZZZ'dxd&0 d d\\\\'dxd&P d d)Hairline d]]]]7HairlinedxdL`abcdef#t37=CIQYag1.a.i.(1)(a)(i)1)a)(O+$0  2t  a  .3  0` (#(#(b$0  0` (#(#2t   .3  0 ` (#` (#(xj$0  0` (#(#0 ` (#` (#2t(  0  )3  0 (# (#(a$0  0` (#(#0 ` (#` (#0 (# (#2t(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2t(   )3  0h(#h(#(u$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2t  0  )3  0(#(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2t  a  )3  0p(#(#L`abcdefh4G_cgkosw{Bullet ListBullet List>c$"Small Circle"0 Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5Level 1Level 2Level 3Level 4Level 5(5hCEKQW]cioAutoList11.1.1.1.1.1.1.1.(EhCEKQW]cioAutoList21.1.1.1.1.1.1.1.>Thick/Thin 2[ d -dddd? Triple+l d d d    j@j@@"&*333j@7??j@AFF j@ Dq!,,,X X$XXX X X$  _,X  $,,,4XX$3J/g*w d dd Xdd Xdd X,&,&w,@00 ,00 ,n00 +  SS , 0l>8($`x1p. Esss\\%l <<\<\< 8S+ \0SS<< 8UnitedStates  &t& EnvironmentalProtectionAgency# & &t#   Washington,DC20460 =S]S*"S =FormApproved.OMBNo.20500068 P]S]S=%\3 00 S]S ,0P@@i i   &t& NotificationforUndergroundStorageTanks# & &t# =31" 00 ,  ]S]S =*wd d@00 00 n00 ,&,&w,@00 ,@00 ,@00 ,j00 ,'00 ,/00 +  (S  0( ,,  , ,StateAgencyNameandAddress:# ,, (# QSSp<* "UUS Q , ,STATEUSEONLY# ,, # KS<- " 00  SSp 0K 0]Sp S 0 ^: ^, ,IDNUMBER: -]p ]Sp - -]Sp ]p -# ,, ^ ^:# ?S0!  00  ]Sp 0? 0]Spo S 0 ^: ^, ,DATERECEIVED: -]p]Sp - -]Sp]p -# ,, ^ ^:# X]S]qC! 00  ]Sp 0ddX@@   , ,TYPEOFNOTIFICATION# ,,  #   G]SSp2,w"]S]qdd G , , ^: ^ DATEENTEREDINTOCOMPUTER:#  ^ ^: # GS8$w 00  ]SSp h0G  w  &#   wW #ԀA.NEWFACILITY 9]*S 9  w  &#   w #ԀB.AMENDED 9]*] 9  w  &#   wp #ԀC.CLOSURE :]SSp%] : ^: ^ DATAENTRYCLERKINITIALS:#  ^ ^: # 9]S*$ 00 h ]SSp 09_____Numberoftanks0  atfacility 5]]&  } <<]S 5Ѐ_____Numberofcontinuationsheetsattached 7]SSp" ]] 7 ^: ^ OWNERWASCONTACTEDTOCLARIFYRESPONSES,COMMENTS:#  ^ ^:[# Y]S]qD  00 ]SSp 0ddY@@    INSTRUCTIONSANDGENERALINFORMATION ) JSSSp5, { "]S]qdd J4*( {  00   SSSp 4*d d@00 @00 @00 j00 '00 /00 ,&,&,u`` , `` +  (S p D  0(3  Pleasetypeorprintinink.Also,besureyouhavesignaturesininkfor  t  sectionsVIIIandXI.Completeanotificationformforeachlocationcontainingundergroundstoragetanks.Ifmorethan5tanksareownedatthislocation,youmayphotocopypages3through5andusethemforadditionaltanks.Theprimarypurposeofthisnotificationprogramistolocateandevaluateundergroundstoragetanksystems(USTs)thatstoreorhavestoredpetroleumorhazardoussubstances.Theinformationyouprovidewillbebasedonreasonablyavailablerecords,orintheabsenceofsuchrecords,yourknowledgeorrecollection.E EG GFederallawrequiresUSTownerstousethisnotificationformforall xL) USTsstoringregulatedsubstancesthatarebroughtintouseafterMay8,1986,orUSTsinthegroundasofMay8,1986E EFFthathavestoredregulatedsubstancesatanytimesinceJanuary1,1974.TheinformationrequestedisrequiredbySection9002oftheResourceConservationandRecoveryAct(RCRA),asamended.G GE E R&. T8 T`8  WhoMustNotify? Section9002ofRCRA,asamended,requiresownersof `/ USTsthatstoreregulatedsubstances(unlessexempted)tonotifydesignatedStateorlocalagenciesoftheexistenceoftheirUSTs. Ownerisdefinedas:L gL`abcdef4h#_L L3   T(0 X,,,4X0L3a243  0    InthecaseofanUSTinuseonNovember8,1984,orbroughtintouse (3 afterthatdate,anypersonwhoownsanUSTusedforstorage,use,ordispensingofregulatedsubstances;orL3a݌  A A Ќ   L3   T2L3243  0    InthecaseofanUSTinusebeforeNovember8,1984,butnolongerin 26 useonthatdate,anypersonwhoownedtheUSTimmediatelybeforeitsdiscontinuation.L3X݌  A A Ќ  T<Also,iftheStatesorequires,anyfacilitythathasmadeanychangestofacilityinformationorUSTsystemstatus,mustsubmitanotificationform(onlyamendedinformationneedstobeincluded).TF  WhatUSTsAreIncluded? AnUSTsystemisdefinedasanyoneor F < combinationoftanksthat(1)isusedtocontainanaccumulationofregulatedsubstances,and(2)whosevolume(includingconnectedundergroundpiping)is10%ormorebeneaththeground.RegulatedUSTsstorepetroleumorhazardoussubstances(seethefollowing WhatSubstancesAreCovered). =S* #!AS =3L7TX X3 WhatTanksAreExcludedFromNotification?   t B hc  3L7TXL7TX3hc"0    TanksremovedfromthegroundbeforeMay8,1986;hc݌2  CL&L& Ќ  L gL`abcdef4hhgL`abcdefL L3   3LLTXL7TX3L3243  0    Farmorresidentialtanksof1,100gallonsorlesscapacitystoringmotorfuel  D fornoncommercialpurposes;L3M݌ L&L& Ќ   L3   L3L 243  0    Tanksstoringheatingoilforuseonthepremiseswherestored;L3L w ݌ FL&L& Ќ   L3   L3?!243  0    Septictanks;L3?!j!݌zNGL&L& Ќ   L3   L3"243  0    Pipelinefacilities(includinggatheringlines)regulatedundertheNaturalGas  H PipelineSafetyActof1968,ortheHazardousLiquidPipelineSafetyActof1979,orwhichisanintrastatepipelinefacilityregulatedunderStatelaws;L3"+"݌ L&L& Ќ   L3   L3#243  0    Surfaceimpoundments,pits,ponds,orlagoons;L3##݌KL&L& Ќ  3L7TXLLTX3 L3   L3$243  0    Stormwaterorwastewatercollectionsystems;L3$$݌T(LL&L& Ќ   L3   L3%243  0    Flowthroughprocesstanks;L3%%݌ML&L& Ќ   L3   L3o&243  0    Liquidtrapsorassociatedgatheringlinesdirectlyrelatedtooilorgas xLN productionandgatheringoperations;L3o&&݌ L&L& Ќ   L3   L3'243  0    Tanksonorabovethefloorofundergroundareas,suchasbasementsor pP tunnels;L3''݌ L&L& Ќ   L3   L3(243  0    Tankswithacapacityof110gallonsorless.L3((݌RL&L& Ќ  TzR& WhatSubstancesAreCovered? ThenotificationrequirementsapplytoUSTs zS containingpetroleumorcertainhazardoussubstances.Petroleumincludesgasoline,usedoil,dieselfuel,crudeoiloranyfractionthereofwhichisliquidatstandardconditionsoftemperatureandpressure(60degreesFahrenheitand14.7poundspersquareinchabsolute).HazardoussubstancesarethosefoundinSection101(14)oftheComprehensiveEnvironmentalResponse,CompensationandLiabilityActof1980(CERCLA),withtheexceptionofthosesubstancesregulatedashazardouswasteunderSubtitleCofRCRA.T^6  WhereToNotify? Sendcompletedformsto: ^[  WhenToNotify? 1.OwnersofUSTsinuseorthathavebeentakenoutof \b operationafterJanuary1,1974,butstillintheground,mustnotifybyMay8,1986.2.OwnerswhobringUSTsintouseafterMay8,1986,mustnotifywithin30daysofbringingtheUSTintouse.3.IftheStaterequiresnotificationofanyamendmentstofacility,sendinformationtoStateagencyimmediately.T"!b"6! Penalties: Anyownerwhoknowinglyfailstonotifyorsubmitsfalseinformation "!g shallbesubjecttoacivilpenaltynottoexceed$11,000foreachtankforwhichnotificationisnotgivenorforwhichfalseinformationisgiven.5+)#"i 00 S 5*fd du`` `` ,&,&f,@00 ,@00 ,@00 ,00 +  8]S]q# $|#i 0dd8@   W I.OWNERSHIPOFUST(s) #  W0#`0Ԉ D]Z]Sq/#$#j]S]qdd ddD@3J W  II.LOCATIONOFUST(s) #  W[1#91Ԉ MS]:+$#k 00  ]Z]Sqdd 0M ,,  ^: ^, ,OwnerName(Corporation,Individual,PublicAgency,orOtherEntity)# ,, ^ ^::2# 2]S%$lS] 2 ^: ^, ,IfrequiredbyState,givethegeographiclocationofUSTsbydegrees,minutes,and %$m seconds.Example:Latitude42$36'12"N,Longitude85$24'17"W 2&%n <&%&%@"J Latitude________________Longitude________________  &%o # ,, ^ ^:2# LS=2z)N(tQQ 00  ]S W0L "&\%uS " ] &\%v  /S&\%w] / ^: ^, , >]S/$X&,%w 00 W S 0># ,, ^ ^:45# ^: ^, ,StreetAddress# ,, ^ ^:5#E  ԍ  ԍEG  ԍG_H  ԍ  ԍ  ԍ  ԍHI  ԍII  III  ԍ̎__  &]'&x]S & +]]'&y] + /]]S'&z]] / ^: ^, ,FacilityNameorCompanySiteIdentifier,asapplicable# ,, ^ ^:7# OS@2'&{]vv  00  ]]S ,0O %('|S % .]('} . +]('~] +4*((['~ 00 ,  ] 4*d d@00 @00 @00 00 ,&,&,00 ,00 +  /S] )(~ 0/ ^: ^, ,County @]]S-'0+*0S] @0IfaddressisthesameasinSectionI,checktheboxandproceedtosectionIII. )( 0  Ifaddressisdifferent,enteraddressbelow: x&x& StreetAddressCounty PSA2,+ 0 00  ]]S ,0P  ^ ^: .]*_)S .4*(*_) 00 ,  ] 4# ^: ^ Ń;#*fd d00 00 ,&,&f, 00 ,00 ,e00 ,00 +  $]S +* 0$City ']]+*]S 'State +]]]+*]] +ZipCode 2]S+*]]] 2 LS=2+*]vv& 00  ]S ,0L '],+S ' +]],+] + /]S,+]] /  ^ ^:4*(,c+ 00 ,  ]S 4# ^: ^ ʼn>#* d d 00 00 e00 00 ,&,&,00 , 00 ,00 ,B00 +  (]S] -, 0(PhoneNumber(IncludeAreaCode) ']]-,]S] 'City ']]-,]] '@hhBState +]]S-,]] +ZipCode ?SS],!-, 00  ]]S 0? )]S/-SS] ) )]S/-]S ) +]SS/-]S +1'%/- 00   ]SS 1* ,d d00 00 00 B00 ,&,&,%00 +   /^. /./. EPAForm75301(Rev.H11HI9I98) Electronicandpaperversionsacceptable..$.$G|&Page1of5 /. Previouseditionsmaybeusedwhilesupplieslast. 30/   0/ *U&'d ,d%00 ,&,&U,@00 ,00 ,n00 +  SS , 0l>#8($`x1p. Esss\\%l .S!\0SS . UnitedStates  &t& ^ ^:EnvironmentalProtectionAgency# ^: ^& &t]S]Sq)<S dd>@  W VIII.CERTIFICATION(ReadandsignaftercompletingALLSECTIONSofthisnotificationform)#  Wb# bԈ ESS2# =]S]Sqdd E  IcertifyunderpenaltyoflawthatIhavepersonallyexaminedandamfamiliarwiththeinformationsubmittedinSectionsIthroughXIofthisnotificationformandallattacheddocuments,andthatbasedonmyinquiryofthoseindividualsimmediatelyresponsibleforobtainingtheinformation,Ibelievethatthesubmittedinformationistrue,accurate,andcomplete. 6]S'"#T"@SS 6cNameandofficialtitleofownerorownersauthorizedrepresentative(Print) 3]]$*'%E]S 3Signature (]$#F]] ( +]]S$#G] +DateSigned 8]SSS%$#H]]S 8 @PaperworkReductionActNotice  \(0'I  ^: ^ EPAestimatespublicreportingburdenforthisformtoaverage30minutesperresponseincludingtimeforreviewinginstructions,gatheringandmaintainingthedataneededandcompleting ('J andreviewingtheform.SendcommentsregardingthisburdenestimatetoDirector,OP,RegulatoryInformationDivision(2137),U.S.EnvironmentalProtectionAgency,401MStreet,WashingtonD.C.20460,marked AttentionDeskOfficerforEPA.Thisformamendsthepreviousnotificationformasprintedin40CFRPart280,AppendixI.Previouseditionsofthisnotificationformmaybeusedwhilesupplieslast. 2("*r)M]SSS 2+U*+* EPAForm75301(Rev.J11JK9K98) Electronicandpaperversionsacceptable.##FG&Page2of5 +U*N Previouseditionsmaybeusedwhilesupplieslast. ,*O     ,+O *78d  d dd g dd Ldd Ldd 34,&,&,@00 ,00 ,n00 +  SS , 0l>8($`x1p. Esss\\%l <<\<\< 8S+ \0SS<< 8UnitedStates  &t& ^ ^:EnvironmentalProtectionAgency# ^: ^& &tl#   Washington,DC20460 =S]S*"S =FormApproved.OMBNo.20500068 P]S]S=%tH3 00 S]S ,0P@@i i   &t& ^ ^:NotificationforUndergroundStorageTanks# ^: ^& &tm# =31" 00 ,  ]S]S =*w9d d@00 00 n00 78,&,&w,dd ,dd ,dd ,dd ,dd ,dd +  2S]Sq ~ dd2@ W ^ ^: IX.DESCRIPTIONOFUNDERGROUNDSTORAGETANKS(Completeforalltanksandpipingatthislocation.) # ^: ^ Wo#oԈ 7S(# S]Sqdd 7  ^ ^:TankIdentificationNumber *]V* S *TankNo.A])dEA *]V* ] *TankNo.A])dEA *]V* ] *TankNo.A])XdEXA *]V* ] *TankNo.A]) dE A .]SV*] .TankNo.A])$dE$A ']SV*]S ' 1.StatusofTank (checkonlyone)  CurrentlyInUse \ P P TemporarilyClosed" " PermanentlyClosed 0]]!b 6]S 0 R & \ & f: & 9]]*D "]] 9& \ & f: & 9]]*D "]] 9& \ & f: & 9]]*D "]] 9& \ & f: & =]]S*D  "]] =& \! & f:" & 0]S!D #"]]S 0  R 2.DateofInstallation (month/year) ']] $]S ' ']] %]] ' ']] &]] ' ']] ']] ' +]]S (]] + ']S )]]S ' 3.EstimatedTotalCapacity (gallons) ']] *]S ' ']] +]] ' ']] ,]] ' ']] -]] ' +]]S .]] + ']S /]]S ' 4.MaterialofConstruction (checkallthatapply) R & 0   AsphaltCoatedorBareSteelCathodicallyProtectedSteel̀CoatedandCathodicallyProtectedSteelComposite(SteelCladwithFiberglass)FiberglassReinforcedPlasticLinedInteriorExcavationLinerDoubleWalledPolyethyleneTankJacketConcreteUnknownIfOther,pleasespecifyhereCheckboxiftankhaseverbeenrepaired 9]]*N0]S 9 R f& L P & FQ & @R & :S & 4T & .U & (V & "W & X & Y & Z A]) xdEA \ A]) xdEA ^ & 9]]*`"]] 9& L b & Fc & @d & :e & 4f & .g & (h & "i & j & k & l A]) xdEPA n A]) xdEPA p & 9]]*r"]] 9& L t & Fu & @v & :w & 4x & .y & (z & "{ & | & } & ~ A]) xdEA  A]) xdEA  & 9]]*"]] 9& L  & F & @ & : & 4 & . & ( & " &  &  &  A]) xdEA  A]) xdEA  & =]]S*"]] =& L  & F & @ & : & 4 & . & ( & " &  &  &  A]) xdE`"A  A]) xdE`"A  &#  R{# 3]S$"]]S 3 5.PipingMaterial(checkallthatapply) f f fBareSteel x  GalvanizedSteelFiberglassReinforcedPlastic$ $ Copper CathodicallyProtectedt t DoubleWalled< < SecondaryContainment Unknown Other,pleasespecify 3]]$%X$]S 3 R f& x & r & l &  f & !`  & "Z! & #T" & z$N# A]) xdEm&A n&B% A]) xdEh'A i'=& #  R9# R  <]]-j'>&"]] <& x & r & l &  f & !`  & "Z! & #T" & z$N# A]) xdEPm&A n&B% A]) xdEPh'A i'=& #  R# R  <]]-j'>&"]] <& x & r & l &  f & !`  & "Z! & #T" & z$N# A]) xdEm&A n&B% A]) xdEh'A#  R# R  <]]-i'=&"]] <& x & r & l &  f & !`  & "Z! & #T" & z$N# A]) xdEm&A n&B% A]) xdEh'A i'=& #  R֌# R  @]]S-j'>&"]] @& x & r & l &  f & !`  & "Z! & #T" & z$N# A]) xdE`"m&A n&B% A]) xdE`"h'A i'=& #  Rʎ# 2]SS!j'>&"]]S 2f 6.PipingType ZZ SafeSuction(novalveattank) )' Ѐ(Checkallthatapply)"" U.S.Suction(valveattank) *(  Pressure GravityFeedCheckboxifpipinghaseverbeenrepaired 2]]S!-+]SS 2 R f& )' & *( & +) & ,* & ;]]S*,+"]]S ;& )' & *(  & +)  & ,*  & ;]]S*,+ "]]S ;& )'  & *( & +) & ,* & ;]]S*,+"]]S ;& )' & *( & +) & ,* & =]]SS*,+"]]S =& )' & *( & +) & ,* &#  Ry# 2(,+"]]SS 2 EPAForm75301(Rev.L11LM9M98) Electronicandpaperversionsacceptable.##FH&Page3of5 .z- Previouseditionsmaybeusedwhilesupplieslast.)4/.   )  0. J/g J, J  *1d  ddd dd dd dd dd dd 9,&,&,@00 ,00 ,n00 +  SS , 0l>:8($`x1p. Esss\\%l <<\<\< 8S+ \0SS<< 8UnitedStates  &t& EnvironmentalProtectionAgency# & &t2#   Washington,DC20460 =S]S*"S =FormApproved.OMBNo.20500068 P]S]S=%xL3 00 S]S ,0P@@i i   &t& NotificationforUndergroundStorageTanks# & &t# =31" 00 ,  ]S]S =*w?@d d@00 00 n00 1,&,&w_,0dd ,Tdd ,Tdd ,Tdd ,Ddd ,\dd ,\dd ,Tdd ,Tdd ,Xdd ,Xdd +  S | TankIdentificationNumber .]  S .TankNo.A])dEA 1]"  ] 1TankNo.A])dEA 1]"  ] 1TankNo.A])XdEXA 1]"  ] 1TankNo.A]) dE A 5]S"  ] 5TankNo.A])$dE$A *]S ]S *f 7.SubstanceCurrentlyStored(orlast  Gasoline > Ѐ storedinthecaseofclosedtanks)  Diesel + Ѐ(Checkallthatapply)  Gasohol   Keroseneb b HeatingOil UsedOilhhIfOther,pleasespecifyhere 4]]% ]S 4 R & > &  &  &  &    &  h ! #  R#A]) xdE A  # A]) xdE A R  @]]1" &"]] @& >' & ( & ) & * &  + &  h , #  R #A]) xdEh A  . A]) xdEh A R  @]]1" 1"]] @& >2 & 3 & 4 & 5 &  6 &  h 7 #  R#A]) xdE A  9 A]) xdE A R  @]]1" <"]] @& >= & > & ? & @ &  A &  h B #  Rp#A]) xdE A  D A]) xdE A R  D]]S1" G"]] D& >H & I & J & K &  L &  h M #  R"#A]) xdE`" A  O A]) xdE`" A <XS-" R"]]S <  #  #HazardousSubstance  T CERCLAnameand/orCASnumber =X].X3XS = R &#  R#  U Y A]) xdEZA [/\ A]) xdEWA @X]1"X,_"X] @ R &#  R3#  U ` A]) xdEhZA [/c A]) xdEhWA @X]1"X,f"X] @ R &#  Ri#  U g A]) xdEZA [/j A]) xdEWA @X]1"X,m"X] @ R &#  R#  U n A]) xdEZA [/q A]) xdEWA DX]S1"X,t"X] D R &#  Rٯ#  U u A]) xdE`"ZA [/x A]) xdE`"WA <XS-"X,{"X]S <  #  #MixtureofSubstances ,} Pleasespecifyhere =X].(3XS = R &#  R#  A]) xdEA  A]) xdEA  A]) xdEA   @X]1""X] @ R &#  R#  A]) xdEhA  A]) xdEhA  A]) xdEhA   @X]1""X] @ R &#  R2#  A]) xdEA  A]) xdEA  A]) xdEA   @X]1""X] @ R &#  Rն#  A]) xdEA  A]) xdEA  A]) xdEA   DX]S1""X] D R &#  R|#  A]) xdE`"A  A]) xdE`"A  A]) xdE`"A   6]S'""X]S 68. ReleaseDetection (checkallthatapply)  f0    Manualtankgauging W  0 @ #  W#Tanktightnesstesting .  W  0 @ #  W7#InventoryControl ]1  W ~ ~ 0 @ #  W#Automatictankgauging `  W  0 @ #  WL#Vapormonitoring   W ` ` 0 @ #  WӼ#Groundwatermonitoring   W " " 0 @ #  W`#Interstitialmonitoring   W BB0 @ #  W#Automaticlineleakdetectors H  0 @ LinetightnesstestingNoreleasedetectionrequired(suchassometypesofbbsuctionpiping,emergencygeneratortanksorfield constructedtanks)Othermethodallowedbyimplementingagency (suchasSIR) 3]]$$#]S 3 TANK      R &    R# R z#&     R# R #& J  dSd R# Rd dS2#& f:  dSd R# Rd dS#& V  dSd R# Rd dS#& r   R# R F#&    R# R Ң#& !T    R# R #& @]]S-$""]] @   RPIPE# R #    { R# R {#&  R  &# R @#  & {O &  uI & oC  dSd R# Rd dS#& _  dSd R# Rd dSk#& {   R# R #&   dSd R# Rd dS##&    R# R #& E    R# R #& <]]-t!H "]]S <   RTANK   # R a#  R# R ſ#&    R# R #&     R# R w#& J  dSd R# Rd dS#& f:  dSd R# Rd dS/#& V  dSd R# Rd dS#& r   R# R #&     R# R C#& !T    R# R #& @]]S-$""]] @   RPIPE# R ,#    { R# R {#  R&  # R #& U & {O & uI & oC  dSd R# Rd dS#& _  dSd R# Rd dS #& {   R# R h#&   dSd R# Rd dS#&    R# R #& E !   R# R |#& <]]-t!H #"]]S <   RTANK  $ # R #  R# R `#& &   R# R ż#&  (   R# R #& J*  dSd R# Rd dSt#& f:,  dSd R# Rd dS#& V.  dSd R# Rd dS,#& r0   R# R ň#& 2   R# R #& !T 6   R# R C#& @]]S-$"9"]] @   RPIPE# R #  :  { R# R {+#  R& < # R ~#& U= & {O> &K uI? & oC@  dSd R# Rd dSQ#& _B  dSd R# Rd dS#& {D   R# R #& F  dSd R# Rd dSe#& H   R# R #& E J   R# R #& <]]-t!H L"]]S <   RTANK  M # R #  R# R #& O   R# R ]#&  Q   R# R Ź#& JS  dSd R# Rd dS#& f:U  dSd R# Rd dSq#& VW  dSd R# Rd dS#& rY   R# R )#& [   R# R ҅#& !T _   R# R #& @]]S-$"b"]] @   RPIPE# R n#  c  { R# R {#  R& e # R #& Uf & {Og & uIh & oCi  dSd R# Rd dS#& _k  dSd R# Rd dSN#& {m   R# R Ū#& o  dSd R# Rd dS#& q   R# R b#& E s   R# R Ҿ#& <]]-t!H u"]]S <   RTANK  v # R D#  R# R Ţ#& x   R# R #&  z   R# R Z#& J|  dSd R# Rd dS#& f:~  dSd R# Rd dS#& V  dSd R# Rd dSn#& r   R# R #&    R# R &#& !T    R# R #& @]]S-$""]] @   RPIPE# R #    { R# R {m#  R&  # R #& U & {O & uI & oC  dSd R# Rd dS#& _  dSd R# Rd dS#& {   R# R K#&   dSd R# Rd dS#&    R# R #& E    R# R _#& 3S$t!H "]]S 3**  RPleasespecifyothermethodhere +]]&$S +A]) xdE&A &h% A]) xdE'A '&  .]]'&]] .A]) xdEh&A &h% A]) xdEh'A '&  .]]'&]] .A]) xdE&A &h% A]) xdE'A '&  .]]'&]] .A]) xdE&A &h% A]) xdE'A '&  2]]S'&]] 2A]) xddE`"&A &h% A]) xdE`"'A '&  ,]SS'&]]S , 9.SpillandOverfillProtection  ('  Overfilldeviceinstalled> > Spilldeviceinstalled 6]]S%+)]SS 6 R & )( & B]]S1"*)"]]S B& )( & B]]S1"*)"]]S B& )( & B]]S1"*)"]]S B& )( & D]]SS1"*)"]]S D& )( &#  Rs# 5+"*)"]]SS 5E,+,V+ EPAForm75301(Rev.N11NO9O98) Electronicandpaperversionsacceptable.##FH&Page4of5 E,+ Previouseditionsmaybeusedwhilesupplieslast.),+    )_  -u, *ABd d0dd Tdd Tdd Tdd Ddd \dd \dd Tdd Tdd Xdd Xdd ?@,&,&,@00 ,00 ,n00 +  SS , 0l>C8($`x1p. Esss\\%l <<\<\< 8S+ \0SS<< 8UnitedStates  &t& EnvironmentalProtectionAgency# & &t#   Washington,DC20460 =S]S*"S =FormApproved.OMBNo.20500068 P]S]S=%xL3 00 S]S ,0P@@i i   &t& NotificationforUndergroundStorageTanks# & &tK# =31" 00 ,  ]S]S =*wFGd d@00 00 n00 AB,&,&w,[dd ,<< ,<< ,<< ,<< ,<< +  S | TankIdentificationNumber *]  S *TankNo.A])dEA *]  ] *TankNo.A])dEA *]  ] *TankNo.A])XdEXA *]  ] *TankNo.A]) dE A .]S  ] .TankNo.A])$dE$A ;]SSq& ]S dd;   W X.CLOSUREORCHANGEINSERVICE #  W# =]S.,> ]SSqdd = L nEh(hgL`abcdefL L3   N% X9 H [X , H [XNL32Eh  1  .3  0 X   ClosureorChangeinService L3݌ZX#X# Ќ    #EstimateddatetheUSTwaslastusedforstoringregulated v #substances(month/day/year)cc#Checkboxifthisisachangeinservice#  M# 0]]! ]S 0  w  #   wӎ#A]) xdE2 A 3    #  (#  w  &#   wk# 9]]* "]] 9  w  #   w#A]) xdEJ2 .A 3    #  ń#  w  &#   w# 9]]*  "]] 9  w  #   wF#A]) xdE2 .A 3 #   #  #  w  &#   w## 9]]* %"]] 9  w  #   wӢ#A]) xdE2 .A 3 (   #  <#  w  &#   w# =]]S* *"]] =  w  #   w#A]) xdE<"2 4A 3 -   #  Ŝ#  w  &#   w# 0]S! /"]]S 0fae 9  2. X TankClosure  e 9 0 #  Estimateddatetankclosed(month/day/year) a 5 2   #(checkallthatapplybelow)#Tankwasremovedfromground  #Tankwasclosedinground#Tankfilledwithinertmaterialuu#Describetheinertfillmaterialhere#  #ӈ 0]]!><]S 0  w  #   wӒ#A]) xdE A  @   w  &#   w-#  B   w  &#   wӉ# C   w  &#   w# D A]) xdEA G A]) xdEA 9]]*J"]] 9  w  #   w#A]) xdEJ .A  N   w  &#   wӮ#  P   w  &#   w # Q   w  &#   we# R A]) xdEJ.A U A]) xdEJ.A 9]]*X"]] 9  w  #   wӔ#A]) xdE .A  \   w  &#   w/ #  ^   w  &#   wӋ # _   w  &#   w # ` A]) xdE.A c A]) xdE.A 9]]*f"]] 9  w  #   w #A]) xdE .A  j   w  &#   wӰ #  l   w  &#   w # m   w  &#   wg # n A]) xdE.A q A]) xdE.A =]]S*t"]] =  w  #   wӚ #A]) xdE<" 4A  x   w  &#   w5#  z   w  &#   wӑ# {   w  &#   w# | A]) xdE<"4A  A]) xdE<"4A 2]S]!"]]S 23. X SiteAssessment  b //#  Checkboxifthesiteassessmentwascompleted ^ #Checkboxifevidenceofaleakwasdetected#  _#Ԉ 2]]]!V]S] 2  #  W#  w  &#   wӚ# ^2   w  &#   w# ;]]]*^2"]]] ;  #  v#  w  &#   wӹ# ^2   w  &#   w# ;]]]*^2"]]] ;  #  ŕ#  w  &#   w# ^2   w  &#   w3# ;]]]*^2"]]] ;  #  Ŵ#  w  &#   w# ^2   w  &#   wR# =]]]S*^2"]]] =  #  #  w  &#   w# ^2   w  &#   ws# GS]Sq2^2"]]]S ddG@  W XI.CERTIFICATIONOFINSTALLATION(COMPLETEFORUSTSYSTEMSINSTALLEDAFTERDECEMBER22,1988) #  W%#Ԉ ?SXS,#2S]Sqdd ? 򀀀InstallerOfTankAndPipingMustCheckAllThatApply:    P      X H&H&QH& 6S'zNSXS 6# a' Installercertifiedbytankandpipingmanufacturers  ii#Installercertifiedorlicensedbytheimplementingagency#Installationinspectedbyaregisteredengineer#Installationinspectedandapprovedbyimplementingagency#Manufacturersinstallationchecklistshavebeencompleted#AnothermethodallowedbyStateagency #Ifso,pleasespecifyhere#  a'#Ԉ <]-\"0!S <  w  &#   w`#    w  &#   w#    w  &#   w*# xL   w  &#   wӆ#    w  &#   w# D    w  &#   w># !~  A]) xdE#A #Z" A]) xdEr$A <]-s$G#"] <  w  &#   wp#    w  &#   w#    w  &#   w(# xL   w  &#   wӄ#    w  &#   w# D    w  & !~  #   w< #A]) xdEJ#.A #Z" A]) xdEJr$.A <]-s$G#"] <  w  &#   wn!#    w  &#   w!#    w  &#   w&"# xL   w  &#   wӂ"#    w  &#   w"# D    w  &#   w:## !~  A]) xdE#.A #Z" A]) xdEr$.A <]-s$G#"] <  w  &#   wl$#    w  &#   w$#    w  &#   w$%# xL   w  &#   wӀ%#    w  &#   w%# D    w  &#   w8&# !~  A]) xdE#.A #Z" A]) xdEr$.A @]S-s$G#"] @  w  &#   wn'#    w  &#   w'#    w  &#   w&(# xL   w  &#   wӂ(#    w  &#   w(# D    w  &#   w:)# !~  A]) xdE<"#4A #Z" A]) xdE<"r$4A 8]SSS%s$G#"]S 8SignatureofUSTInstallerCertifyingProperInstallationofUSTSystem̀A])T` dETV'` A߀A])*` dE*V'` A߀A])&` dE&V'` A &% 0 X 09XH&XH&09H&9H&Name0 H&H&0H H& H&0[H H&H H&0[H&[H&Signature0H&H&0H&H&0XH&H&0XH&XH&DateU')&H&H& ̀A])T` dET(` A߀A])*` dE*(` A߀ A(' 0 X 09XH&XH&09H&9H&Position0 H&H&0H H& H&0[H H&H H&0[H&[H&Company 6,#-)(H&H&]SSS 6 EPAForm75301(Rev.P11PQ9Q98) Electronicandpaperversionsacceptable.##FH&Page5of5 _*3)  Previouseditionsmaybeusedwhilesupplieslast)*)   )