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i S'RUCI"IC)N s FOR 0`MPI x CI*'B'
<br /> 6PIRAL INS`ISI C-1-TO n
<br /> 1. One FORM"II"shad be cotrtpteted for each tank for all NEW PERMrIN,Pl,,Rmrr C HA GE,% I EMOVAI S and/or any
<br /> otherTANK:ASI IX)R 'I`IC)N C:IANGB
<br /> 2. This form should be completed by either the P13RMIT APPLIC'ANI'car the LOCAL AGENCY UNDERGROUNDTANK
<br /> INSI'I�.C70
<br /> 1 Please type or print dearly all requeste=d information.
<br /> 4, Use a hard paint writing instrument,you are making 2c pies.
<br /> 'FOP OF lf?ORM.�MARK ONLY Oblif mw
<br /> 1» _'Mark an CQ in the:box n6t to tea I£dstli ffiat gest°describes else xeca t�ii Y�ae f<iin�is beiat�ccrnpleteti.
<br /> . Indicate the DBA or Facility narne where the tank is installed.
<br /> I. "TANK l?SC J ION-C MPW,11I3 AIL ri-EMS-Ill UNKNOWN m SO STI—117 Y
<br /> A. Indicate c r tank:11)# µIf there: is a tank number that is used by tete owner t4tt (ex.AII70789).
<br /> B. Indicate the name of the company that manufacturrcd the tank(ex.ACMETANK MFG.),
<br /> C. Indicate the year the tank was installed(ex. 1987),
<br /> I3. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc,),
<br /> H. 'TANK(X) 17N`I S
<br /> A, L If MOTOR 4°HUCIT FUEL,check box 2 and complete Berns II& C.
<br /> 2.If not MOTOR Vl-J IICLE I' IsL,check the appropriate box in section A and complete items B. &D.
<br /> B. Check the appropriate box,
<br /> C. Check the type of MOTOR VEIIIC,IJ.;',FUEL(if box 1 is checked in A).
<br /> D) Print the chemical name of the hazardous substance stored in the dank and the C,A.S, .(Chemical Abstract Service
<br /> number),if box 1 is NOT checked in A.
<br /> III. 'JANK C ONSTRU(:110 l-MARK ONE r1MM ONLY IST, I3,C&I7
<br /> I. Check only one item inTYPE or,ssyS'i"I3'41,TANI T:M 'RIAL, I.N I11,RIOR LINING and CORROSION I'ItOT ("I"IO .
<br /> 2, if OTHER,print in the space p:rovideti.
<br /> IV. PIPING I R A`I"IO
<br /> L Circle A.if above ground; circle U if underground;and circle both if applicable.
<br /> 1 If UNKNOWN,circle,', or if O'DIFT,print in spice provided.
<br /> 3. Indicate.the LEAK C)HI`I{.t;°I'ION system(s) used to comply with the monitoring requirement for the piping.
<br /> Vo TANK LEIC D ITX71I I
<br /> 1. indicate the I.,r'AK D13[ECTION sy'stere(s) used tea comply with the ntcanitsiring requirements for the tank.
<br /> STI. I I°C) § Aa 'ION ON Tri I*I?IC 1!N``r,Y C"u3,sm IN PLA(I?
<br /> 1. ES: I`I ATED DNIT.IASI`USI3I)-Mf NTI`fIfYHAE2 (January, 1988 or
<br /> 1 EgFIMA` L-d)OUANITI of IIA TrtldDOUS SL;I34"I`ANCE remaining in the tank (in Gallons),
<br /> 3. WAS'I'ANK FILLS WITH IN K"[:'MATT AL,? Check 'Yes'or'NO'.
<br /> APPI.I(' ISI"S1ON AND I Xpl!-1-11H FORM AS INDIC HIED,
<br /> IN I'RU(T11ON FOR 1`I1?LOCAL ACHINCI1$I
<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 (91.6)739-2421. `Fhe facility number must be the same as shown in form 'A.". The
<br /> hank nurexber may be assigned by the tocat agency-, however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Roared to ass'sgm the tank number,please leave; it blank,
<br /> ITIS ITIF,RESPONSIBITXPY OF 111E LOCAL AG:. C 'nl/VI'I SP I.',S`I 13 FAC I1,r. 1'0 VERIFY"THE
<br /> Iii?
<br /> ACCURACY C OF TIIIA INFORMATION. 171F.LOCAL AGENCY IS RESPONSIBLE FOR'I1IE1 COMPLIBITON()F'7111
<br /> 'LOCAL AGFNCY US14 ONLY'INFORMATION BOX AND FOR FORWARDING ONF FOR `A*AND Ate" CaINI'ED
<br /> I*) 'B'(s)TO"1171;IN ILOWING ADDRI S.
<br /> S'I`e 11?OF CALHURNIA.
<br /> S"IA' a WNIER RESOD C:I C"()2+II'ROL APJ)
<br /> /o&W-nu-B.&
<br /> DNFA PROCESSING .:e 1`f:AIZ
<br /> P.O. BOX 521
<br /> PA CUNT',CA 90723
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