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IN I`RUCe_1"ION S FORCCOMPIZ11NO I"af3 'lig
<br /> CSEWEX AL Ct "I7RJJC:°110Nf;-
<br /> (enc I'ORA413";shall be completed foreach tank for all NEW I"Ii I`I'S,I''I mn,(;`II ANGE , EIMO AUS and/or any
<br /> other`l.AN IN O M -1`IO&CHANGE
<br /> 2. '1 his fornn shta ild be cont lr test by either the Pf .t '- LTC: N`F or the 1,000,AGENCY 7N 3IIRGR 7UND'1 N
<br /> 7-, IlallsPEC''IXYRi I
<br /> 1 Please type or prim,clearly<all < Ipest€d inform tioart.
<br /> 4, r.
<br /> se a ino'l; fiint wrifing(nstcuYnent,yips are making 3 copies.
<br /> 'I°C1"P 017 1X)(tNt -NIJARK ONLY C3I`411 1`11 M'e
<br /> i. Mark an (X)in the;box next to the dean that best describes the reason the form is being completed,
<br /> 2. Indierated the,I.)f3A of Facility name where the tank is installed.
<br /> In 'ANK DE—S ; IVI 4:tF - `SMPLIE1'E Ali,rri -Hz UNKNOWN-4t7: F?CC;1FY
<br /> Ak Indicate earners tank I w If there is a tank number that is used by the owner to identify the tank(ex, r 370789).
<br /> 33. Indicate the na ria of the company that manufactu,ted the t,,mk.,(e<x.AC°,ME'TANK MFG.).
<br /> G.).
<br /> Cr. Indicate the:year the tankwas installed (ex, 'PW).
<br /> D, Indicaw the tank capacity in gallons(ex. 25,000 or 10ete.).
<br /> 11, `I"1lIIII(S``A11csG"S
<br /> A, 1. If yf )3"flrl y LI3 , LI,I l I.I.I,,check box. I and complete Stems 13& C:.
<br /> 3. if rc.,, is(XI'liw VEHICLE L 1 UF,L,check the a,airopri ate box in section A and complete items 13 & D.
<br /> &1, c^hec br zrE1. iaie box,
<br /> t,. Chars ;r, ..0," lr.t.f rt=t': `a'Llta=,i.a 1'(_Il i,f'if b x "l is checked if }.
<br /> 1). Print t,. €hcn ica< name,of ihi hazardous subsum es stared in the tank and the (,',A.S, .(C'lremical Abstract Service
<br /> number), if t)oe '. is c heckcd inA,
<br /> 111, 74FANK k .,r x.1 Vit,a.r.Ix1a I_MAIltrK ONE S.,FJti,(0,NLY'IN PX)X II,IS,C&11
<br /> Lna,vZ only ne tm'm fab
<br /> I i z ' I"'... 1,'1r,4 C slra a vi i< L< 11l>IYICiT l,i CI Ca and C'CfI1I3CytiIt'l'S I'Il.t)`il:t,.`ICI�I.
<br /> e,. If C f alai=.,, pr,,_ in fl-,,c Pace 06?d.
<br /> TV, PIPING INFORM �'ITOIN
<br /> 1. C'rel h,f alc ? .ndt circle L!i a dere rormd3 and circle Both if applicable.
<br /> 2, If I " K`,,'Co1,N,cirtic„ or if 0111 R f,# rat in macs:-provided,
<br /> 3. Indicate she I,L gI( >'r.,lI(.,ltf N,e stems)used to comply with the monitoring requirement for the piping,
<br /> , 'WANK a s ALA syr C:"„t0l
<br /> i. lnd, ..i the LI.`Ila ter .=_;C�fM,o t; iE axe.,) ,ised to ccrrnply with the monilorin;realuircnicnts for the tank.
<br /> VL I FCYRNIA"1 ON ON LANK 1'=. NIAI=1g,M11M "LOSia.17 its PLACTi
<br /> C, P�� IMA1'la_)1 AI F LAST" .1 ;FJT/Y II(January, 1988 or 01/88).
<br /> 2. FNI INIXl`I}ly C; J'A,y r frt' o 11AZ1ttlD' 1"S `,l"sI`I'r't NC E' remaining in tire tank(€n Gallons),
<br /> 3, Wrsf YANK 1711,11'1) WI I"tI €NE,1I"f"l4A-IV1R.1 9f..? Check `s'e:s'or'N(-Y.
<br /> AVPfJG`,NFMU9r SIGN AND DA 1e. 1711I 1aURM AS 1113II' 'II I3.
<br /> IN 7I° 1:1 '1"10 F'O 'I11If LOCAL AGENC 1 C
<br /> ]be slate ,,an', identatf.....tron pwnhcr is con,'pcewd of the two digit county number,the three digit jurisdiction
<br /> number, he x d t t r t�t a l r a anu Cf�ti sa lar tank number, 'fie county and jurisdictionnumbers are y t�euctc.rmine f and
<br /> n be o t a r d by cafflinq ihe State Board (916)"r 2421 -11he facility nvtrdxr must be the sante as shown in form _A". `` e
<br /> tank nurn er cabal to a.wttgr,r by Thr locaP '.gency; hcrvever, this number must be numerical and cannot contain an alphabet. If
<br /> the loosd agenq prefam,the St al,,board to assign the:tank number,please leave it blank.
<br /> 1'.l IIS'ITIE RESP(.INSIBILFI CSI '1`IF LO(DA:1 Cf llC `I tl'I" l Ig3?C 3 `73ir F CritYI 'U.)Mill i' 111E
<br /> , CWC'URAC Y OF 1111:1 IN1'"Ci1C.it YV1`l01d. 'I'IIIT,IX1C AL AGENCY S RESPONSIBLE'FOR 1711i COMPLE-ITON 01717111
<br /> 7111
<br /> "110C AL AGFUNCY U S11 ONLY'INF ORMNI ON IXTX AND MIR FORWARDING s ONE FOR ",A'AND W3(°X11',1:3
<br /> FORM'il'O I°c °1 .FOLLOWING 1 RE-S .
<br /> qty)sm,1f,N- n .
<br /> D/U." PR0CMa;STN`G(DENTER
<br /> D.BOX 5
<br /> PARAMOUNT-,C`.a f7?' 3
<br />
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