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IN,qI'RUC11ON,S FOR COMI HIING 1k)RM*W
<br /> GFNERAL IN'T1`RUC17ONS-
<br /> 1. One FORM 113"shall be completed for cac,.h tankh')t all NE,)p`PF'f(M1TI'5,PERVY!'CHANGIN, REMOVAISand/or any
<br /> other'JANK IM7ORNM17ON CHANGE.
<br /> 2, This form should be completed by cfthc, the 1.0(AL AGENCY UNDERGROUND TANK
<br /> INSPW,10R.
<br /> 1 Please type or print clearly all requested informition.
<br /> 4. Use a hard,point writing instrument,you are making 3 aspics:
<br /> 1XV OF FORM:'MARK ONLY ONE TIT241
<br /> L Mark an (X)in the box next to The item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installcd,
<br /> 1. TANK 1)F_SMP'1TON-COMPIZ111 ALL TIEMS-W UNKNOWNSO SFE'Clff
<br /> A. Indicate owners tank TO#-If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.).
<br /> C, Indicate the yqr,the tank was installed (cx, 1987).
<br /> D. Indicate the tank capacity in gallons (ex, 25,000 or 10,(XX)etc,),
<br /> H. TANK CDNIWrS
<br /> A. L If MOTOR VEHIC1.111 FUEL,check box I and complete items B&C.
<br /> 2. If not MOTOR VEITIC1,13 ITUF.I.,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 VEMIC1.11'FUEL(if box 1.is checked in A).
<br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C,A.S.#. (ChertucalAbstract Service
<br /> number),if box I is NOT checked an A.
<br /> III: TANK CONM7RUC170N-MARK ONE 1`111M ONLY IN I3OX A,B,C&D
<br /> I. Check only one item in TYPE OF SYS113M_TANK MATERIAL, INFERIOR LINING and CORROSION PRO'r1-.',cnON.
<br /> 2. If 0111ER,print in the space provided,
<br /> IV. PIPING INFORM/VFION
<br /> L Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or if O'IIIER,print in space provided,
<br /> 3. Indicate die LEAK DE'I'E,'CT1ON system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LK DEFIX7110N
<br /> 1, Indicate the LM K DT,,,'I1'C'rION systeni(s) used to cornply with the monitoring requirements for the tank,
<br /> VI. INIURMAIION ONTANK PJ: MANJfNJJ.y G[A)SED IN PEACH:
<br /> L IISTI[MA'11:1,13 DATE 1AST USE,'D -MC)'. IT/ (January, 1988 or 01/88).
<br /> 1 0511MATED QUANITry of HAVARI)OUS SUJJS,rI'ANCIp"remaining in the tank(in Gallons),
<br /> 3, WAS TANK FILLED WI'ITI INERT MA11"'RIAL? (:'heck 'Yes'or'NO.
<br /> APPIJCANT MUSTSICIN AND DX113 11113 17ORM AS INDICNI17D.
<br /> INS-fRUCIION FOR 11111 IDCAL AGENCIES
<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 (916)739-2421. The facility number nAust be the same as shown in form "A". The
<br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the Stake Board to assign the tank number,please leave it blank,
<br /> rPIS 1111.1 RESPONSIBI1117Y OF 1111.1 LOCAL AGINCY 1,11AFINSPIX,'I'S TIIE FAC 1" TO VERIFT11113
<br /> ACCURACY OF 171F,INFORMKI10N. 11113 LO(Al,AC
<br /> ,wENGY ISRESPONSIBIE 1?OR 11113 COMP11ION OF 11113
<br /> "I C) AGENC—f USH ONLY'INIURMN17ON BOX AND FK)R IiORWARDING O31 M"A!AND ASSO (INPHD
<br /> Ik)RM"B"(s)TO 111.11,]VOLLOWING ADDRESS.
<br /> STNIII OF CALIMRNIA
<br /> ,S1"N111 WN11IR RESOURCES CONI'ROL BOARD
<br /> C/o ILW.1111 K�PS.
<br /> DATA PROCJI.MING CE NIVR
<br /> P.O.BOX 527
<br /> PARAMOUIVI�,CA 90M
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