Laserfiche WebLink
S I'RUC7IIONS FOR COMP ITNG.1X) � ' <br /> GENERAL S I3 0NS- <br /> 1. One I`C>h°M "I3" shall be completed for each tank for all NEW P RMrIN,PERMIT CIIANGEN, REMOVALS and/or any <br /> otherTANK INIURMNITON CHANGE <br /> 2. This form should be completed by either the PERT TP APPUCANr or the IA)C' ,AGENCY Y i1NDERGROUNI3 TANK <br /> INSP� ..I'OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'FOP OF FORM:'MARK ONLY ONE I ifvl" <br /> 1. Mark an (?t) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK I KSC ITON-C:CI PI.T3'IT$All,TFE S-IF UNKNOWN-SO SPFCIIrY <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.AE370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> 11. TANK CONI"E;NI <br /> A. 1.. If MO1'CIRVEHICLE NEJE.,check box 1 and complete items E3 R C. <br /> 2. If not MOTOR VEI-.LICLh FUEL,check the appropriate box in section A and complete items I3 C& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR F"1.1EL(if box 1 is checked in A). <br /> Ly. Print the chemical name of the hazardous substance stored in the tank and the C.:.A.S.#. (Chemical Abstract Service <br /> number), if box 1.is NOT checked in A. <br /> M. TANK CONSI'RUC`I ICFN-MARK ONE rI12A ONLY IN PA)XA,13,C&I3 <br /> 1. Check only one item in'I-YPEi.OF SYSTEM,TANK MATE,'RI.AL, I'N71:IEIRIOR LFNING and CORROSION PRCITEcTION. <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING INF RMA'17)N <br /> L Circle A if above ground; circle I7 if underground; and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OT:'kLET,print in space provided. <br /> 3. Indicate the LEAK L)ENEC°TION systema) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DINIX,'TC)N <br /> I. Indicate the LEAK L?:FN'FEC"TICIN system(s)used to comply with the monitoring requirements for the tank: <br /> . INIUR A ON CSN"I` PI:FRMANFWII,,Y CI:.CFSFD IN PIACI! <br /> 7.. 13917INIA1 :i>DATE LASI'USED-MC:INTTIi1 R(January, 1988or Ol/£I£§). <br /> 2. E 9171MATED QUA.\71'nY of IIA7AOUS SUBSEA C:L"^ remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED Wrl EI INERT`NIA I'LIRIAL? Check'Yes or'NO'. <br /> APP11 Nr musir SIGN AND DA .,TTIi?FORM IMM(W119-1 <br /> 119-1 <br /> INSI'RII('ITON 17OT 1I?LOCAL AGI?,NC.'IES <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)739-2422. The facility number must 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 State Board to assign the tank number,please leave it blank. <br /> IT IS IIID R 7.SPONSI13I1.,1'1'SI OF T1IE?1 OC.AL AGIY4C Y`I71AT'INSPRUIS,171I:1 TBACI1,I71"Y'TO°VERII"Y''1111? <br /> ACCURACY OF 1311.1 INFORMATION. TIIE UX:AL AGENCY IS RESPONSIBLF FOR ? ;). PLI?11O 017 T'II <br /> > <br /> "LO AGENCY L SI1 ONLY'IIB OR NI-IC?N X )FOR I R ARIFING O ..,t "A"" 'AS'k ..It <br /> IAC) "I3"(a)"1'C)111F.IiOIl, )WING ADDRESS. <br /> S'NIE OF CAIlFDRNIA <br /> 51'A. WA'. R Rim. 1J iCIaS C ONFROL BOARD <br /> C/o S.W_IF.Iff P.S» <br /> P.0) BOX 527 <br /> A _hfC)UNI7,CA(XflZ3 <br />