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SI°IiLI(HONS FOR C OMPL,•, _NCI I -R-
<br /> GENERAL
<br /> R-C3E NERAL I S'I°ILU(7FI 7?NS
<br /> 1. One I`OR "L3"shall be completed for each lank;for all NEW PERMnN P17,,RMrF CHANGYRi, R MOV I S and/or any
<br /> otherTANK X) 'I1O N lI TQC
<br /> 1 This form should tic completed by either the PER TI' PLIOAN"I'or the LOCAL AGENCY UNDERGROUNDTANK
<br /> IN,SPM-- -'O
<br /> 3. Please type or print clearly all requested information.
<br /> 4, Use a hard point writing instrument,you are making:3 r pics:
<br /> TOP OF FORM. 'MARK ONLY ow T 13 "
<br /> L Mark art (X)in the box nest tc�be ifd m thii,St`dcs�Yibes the Vis" 'Ch��`P>i°iin�is being ecn2gic a 1.
<br /> 2. Indicate the DTIA or facility naane where tate tank is installed.
<br /> . >IA :A K ON-(�£W117 I"T"IX -IF UNKNOWN-<' T',C;.
<br /> A. IndicateocvnA* ,,tank`£l.) # -If there;is'a tank number that is used by the owner(o identify the lank(ex.AI370789).
<br /> B, Indicate the namem of the company that manufactured the tank (ex.ACMI R TANK MFG.).
<br /> C. Indicate the,year tate tank w<as installed(ex. 1987),
<br /> D. Indicate time tank capacity in gallons (ex.25,000 or 10,C00etc.).
<br /> A. I. if mo,t,6R VD10,17,FUEL,check box I and complete items 13& C:.
<br /> 2
<br /> I3. C{I f not MOTOR`1,111C LE check the appropriot e box iit section rA and complete items B& D.
<br /> k the appropriate box. 'A.
<br /> Check the type of%AO OR VEHICLE FUEL(if box 1 is checked in A).
<br /> D. Print the chemical:lame of the hazardous substance stored in the tank and the C".A.S. .(Chemical Abstract Service
<br /> number), if box 1 is N07'eheaked in A.
<br /> CIA. 'JANK ON,1 rRUCAi1C)TN-MARK ONE FpEM ONLY IN,1]OX ft, 3,C
<br /> 1.. Check only one item in TYPE(31'SY STt 14,'l`ANK,4MA'I`f, TAL,, IN E'RIOR I. NIS G and CORROSION PRO-173C'110 N.
<br /> 2, If OTHER,print in the space provided.
<br /> IVPIPING INIX)RMA'nON
<br /> 1. Circle A if above ground; circle U if undergrczund; and circle both if applicable,
<br /> 2. If UNKNOWN,OWN, circile-, or if print in space provided,
<br /> 1 Indicate the LEAK DT-0d "IIC)N systern(s) used to comply with the monitoring requirement for the:piping.,
<br /> V. TANK LEAK fr[ii,PIC71
<br /> I. Indicate the LFAIC L11,7FE(710IN system(s) used to comply with the monitoring regcaivernents for the tank.
<br /> y .� a ... 5 '.
<br /> VL
<br /> I °() A'I'IC)N ON-TANK 'i.?R AtN MON C'u)SED IN PLACE
<br /> E
<br /> 1. FSTIM ArED Dikiflt[AST USED-A 0,Nrl'IIpYT:A (.January, 1988 or 01/88).
<br /> 2, ES I;uTN11"t3 OUANTITY of ILAZAL1.DO S SUMSTANCE remaining in the tank (in Gallons).
<br /> 3: WAS 1A NK FILLED WITI I INEKI`MATERIAL?ERIAL? (,heck 'Yes'or'NO' t.
<br /> AI'I"I,I(ANr MUST SICU ANT)6XIV'ITIR FORM AS I DIGNI >).
<br /> 1N51'ILIC'I"I£) IFC7L2'ITIL?LOCAL AG C ULS
<br /> The state underground 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 (41.6)739-2421. The facility number must be the same as shower in Correa"A". The
<br /> tank number may be assigned by the local agency; howeve,Jc this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank,
<br /> A•I'IS 111E RESPO SII31 ,pPY 01711TC1 LOCAL AGENCY Y TIIA I"IMSA' `ISI`7W FAC.IL TO VI3t211741II?
<br /> AC ("Y OF 111E IsCTaOR A'I'ICIN. '11W IDEAL AGENGY IS RESPONSIBLE FOR 17111 C°CIMPL ON OF'1111
<br /> 'LOCAL AGENOY US14 ONL Y'INFORMYVIION BOX AND FOR FORWARDING ONE FORM W AND ATISOCINFED
<br /> IX) 'B'(s)I-011111 FOLIDWING,ADDRLES&
<br /> ,V17SIM OF CA1.11URNIA
<br /> 1'Vk1T 1'A`I".R RE".11R.C.IIS CONI' OL BOARD
<br /> /f)&W nl' P.&
<br /> DA7rA PR.O(,M``ILNGI GNIT.R
<br /> P.O.BOX 527
<br /> b PA OUN"I",CA 90723
<br />
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