|
1, One FOR "I3"shall be completed for each tank for all NEW I'IIIC . 1S,1`11IRM17117 CHANGES, . MOVAT. and/or any
<br /> tuber TANK,INIT)RMA71ION€1ANG
<br /> 2.: This form should he completed by either thePE I PLIC'.r�Nr or the. I: k AGEN(.Y U ERGROU I3"SANK
<br /> INSPEC170R.
<br /> 3, Please type or print clearly all requested information,
<br />` 4. Use a hard point uniting instrument,you are. making 3'c°opies.
<br /> OJT FORM.WARK ONLY f f I'I'I;
<br /> 1.' Mark an (X)in the box next ttt the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> I. TANK EtESCrTtWiTON_COMP1131`13,ALL HEMS s-IF UNKNOWN-SO SPECIFY
<br /> Indicate owners tank l )# -If there is a tank a°aumber'that is used by the owner to identify the tank(ex.A1370789).
<br /> F3. Indicate the name of the company that manufactured the tank(ex.ACME TANK)JFG,).
<br /> C. Indicate the year that tank NY-as installed(ex, 1987),
<br /> I3. Indicate the tank capacity in gallons(ex. 25,E or 13,000 etc.)
<br /> 11. TANK COMPIWn'
<br /> A. I. If IMCi3'I'£:)ii VfilflCLI I`UFL,check box t and complete hems B& C".
<br /> 2. If not MC1`I`OR VF',IIICLE FUEL,check the appropriate box in section r and complete items 13-& hi.
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VEIRCLE F l L if box 1 is checked in A),
<br /> D. Print the chemical name of the hazardous substance,stared in the tank and the:C:.A,S, . (Chemical abstract Service
<br /> nurnbi r), if box I is'.~SOT checked in A,
<br /> III. JANK ON9l.' UC:I.1ON-MARK ONE r11M ONLY IN TIOX A,R,C"&1)
<br /> L Check only one itch,in TYPE OF SYS EM,TANK MATERIAL, INTERIOR LINING and CORROSION T'CRIT t"I"iON.
<br /> 2, ' If OTHER,pr;att in the space;provided,
<br /> IV. PIPING INi<"C3IZMATIt1IV
<br /> L Circle A if above ground; circle U if undergroamrad; and circle both if applicable.
<br /> 2. If UNKNOWN,circle, or if 01111.lR,print in space provided,
<br /> 3. Indicate the 1I�AKFITEX,71ON sy.st~ern(s)used to comply with the monitoring requirement for time piping.
<br /> V. TANK LEAK DINW11ON
<br /> L Indicate the LFAK f,1`FC`FJ0N system(s) used to comply with the ntnniloring ret]airemnents for the tank.
<br /> VI. INFORM)VTION ON TANK f'IfItM I1dV'I1 'CLOSED IN w. I?
<br /> I. ESTIMATE 3 "IT"1AST LISEN-ivlm NT]£I�1 p�Tt �I muama,r,-199,or
<br /> 2. ;sl IM 1`t`I Iy QUANTITY of IIA:?:i11fDOUS SUBS`1ANC.7':r=ctr arcing in the tank(in GrarElons),
<br /> 3. WASTANK I ILL II WITH J,\M.RI"MNF It4I.:$f'hc k 9 resA car"`ffC
<br /> AFRI ., h musr SIGN 3 DA11f.1 f FORM AS V ICNI ,11),
<br /> The state underground storage tank identification numberis composed of the two digit county number, the three digit jurisdiction
<br /> number,the six dight facility nunit:er and the six digit tank:number, Tile county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421, The facility nuniber must be the same as shown in form "A , The
<br /> tank number may be assigned by the local agency; however, this number nmust be nunn rival and cannot contain an alphabet. If
<br /> the local agency prelate;the State Board to assign time tank truant;er, please leave it blank,
<br /> 1I'IS 1IiIf I:�'SIaS SII3IIRTi OF THE LOCAL GEWY 1JI 'I':C SP t I i`I1II If CIi "I C3. ILII ILII?
<br /> CC U C 017 TI I F t1`I ON. '111 I C)(AL AGENCY IS RESPONSIBLE FOR'11111 C".C9 "LE]VI N Oft'1111i
<br /> ILOO L AGENCIY USE ONLY'INFORMA110N II(3K AND Turkic FORWARDING ONE FOR 'A'11Ni5 ASS€3C:NIT1.)
<br /> 5ENIII OF CA, 111k)I2
<br /> DNI'A I'I1.C3(I i&SING CENFER'
<br /> P.O.BOX 527
<br />
|