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INSFRUCIIONS MR C OMPT Crf CI l -Ir <br /> GENERAL INS`I'I€I:7C"1'ICI S. <br /> L One I ORM "I3"shall be completed for each tame for all NF-w Ism s9,PL?,RP rr am:Nc F,S, ' EMOVAI and/or any <br /> otherTANK INIVORMN11ON t ate <br /> 1 This form should be completed by either the P17Rmrr APPI-ICAW or the LOCAI.AGFNCY UNDERG RO TA - <br /> IhISI' 'LII <br /> 3. Please type or print clearly all requested information,. <br /> 4Use to hared point wrifing instrument,you are making 3'ropics. <br /> 'I'OP€R FORM. ' Ilk ONLY ONE rmm, <br /> t <br /> akasi ( ) in ttie faox next to fhc ifeld that beat deserkb <br /> 1; ruses the"reasons fhc form is being completed) <br /> 2. Indicate the DBA or I-aci9ity n<anac where the tank is installed. <br /> I. TANK DFSCRW.119N-C:f °14f]("'I ,' Ia `7 S-IF UNKNOWN-SO SPEC- <br /> A. Indicate'bwn rs t;an ll) --. Macre is a tank nu€ berthat is used by the owner 16-10enth7k the-tank(ex.AB70799). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANKMFG,). <br /> C. Indicate the year the tank was installed (ex. 1937), <br /> 13. Indicate the tank capacity in gallons(ex,2.5,000 or 10,0etc.). <br /> H. TANK€ONFEs '["fs <br /> A. L If MOTOR VI 11IILLf FUEL,check box.I and complete items B& C. <br /> 2. If not MOTOR V.IIIC I,p;112FIL,check the appropriate box in section fA and complete items B & D. . <br /> B, Check the appropriate box. <br /> C, Check the type of MOTOR VEHICLE,ITyi7tL(it box 1 is checked in A), <br /> D, Print the chemical name of the hazardous substance stored in the tank and the C",A,S. . (Chemical Abstract Ser ice <br /> number),if box 1 is Nar checked in A, <br /> III. -rANK coNstZucirfo -mARK Owl,nim ONLY IN 13OX A,If,C;&I3 <br /> I. Check only one item inTYPE"O SYS`I'laK TANK MATERIAL, INI'E'.RIOR LINING and CORROSION I'I2CI"CI~C710 . ; <br /> 2. If CB'HER,print in the space provided. <br /> IV. PIPING INFORMA'VION <br /> 1. Circle A if aboveground;circle U if underground,and circle both if applicable. <br /> 2. If UNIC`1OWN,circle; or if OTI1171B,print in space provided. <br /> 3. Indicate the 1.E�,\K T3ETEC`I'ION systcm(s)used to comply with the monitoring requirement for the pipet& <br /> V. TANK I,I K Dff17EC`I CIN <br /> 1. Indicate the L1 irAK.D1- 1'I C'I'IC"t:S slstem(s) used to comply with the monitoring requirements for the tank. <br /> VI. INfEOR A'I'fON O `rAa K PERMANENpLY CIDSED IN PLACE <br /> 1_ S.plM i'I DAI'E LAS`I`us pt-;AIoN; rtI/Yt:,k (January,1988 or 01 fes). <br /> 2. 172STI A"I'ID QUANTI-I Y of HAZARDOUS Si.IWIANCE remaining in the tank(in Gallons). <br /> 3. UTAS"I,,.x K ILLI-D Wffll INF;IC'I'MiVrERIAL? Check 'Yes'or'N'Cl'. <br /> AI''I.ICSTF SIGN AND 113)VtVT11E IZORM AS I I I AIED, <br /> 1N%'1`RU(:11ON FOR111E LOCAL AGENCIES <br /> The state underground storaf e hank identification number is composed of the two digit county number the three digit jurisdiction <br /> number, the six digit facility number and the six ds` it tank number. The country and jurisdiction numbers are predetermined and <br /> can be obtained by calling the state; Roared (916)739-2421. The facility number must be the same as shown in form"A'.' he <br /> tank number may be assigned by the local agency; however,this number must lienumerical<and cannot contain an alphabet. If <br /> the local agency prefers theSlate board to assign the tank number,please leave it blank, <br /> rl' S 71111"RESPONSRUIXI'Y OFTHE LOCAL ACI C f IIA'['B S'I "IIa"lI:1 I FAC I11FY 10 VEIMIF ZTII• <br /> AC.1q� C CIIF°TIIw IISIF€3 r�`10 . 'ITT 1.0( <A€II NC`Y IS RESPONSIBLE '71E C€9i1 P11N`I€SN OF'1711B <br /> 'LOCAL AG]ENCY USF ONLY'INFORMA71ON BOX AND FOR JX)RWARDING ONE FOR "A"AND AS` C/IN11113 <br /> 'B`(s)`r 'I1IE MI WING ADDRENS. <br /> 9171VI I'`O F C'.A111K) <br /> 5IA7rEWN17R RESOURCES MI'RO,BOARD <br /> J€ S. .I-I-P.s. <br /> DATA IDROC>`ail €i I`F; <br />