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JOWL
<br /> GENERAL ted a t'FCI IC`GONS-
<br /> L One FORUM°T3"shalt be completed for each tank for allNFW E ,.,PERMITC11ANGES, REMI) ' I-'S and/or any
<br /> 2, This fc,,,nn should be completed by either the ' II"APPL1CANI'or the LOCAL AGENCY Y WGROUNDTANK
<br /> T
<br /> INSPECTOR-C" OR-t
<br /> 3. Please t,,pe or rein, eel :arty all requested information.
<br /> i 3°Ae s: laas°l° °i tt gtritrr« a 1ararAtc t, 'oVare rnaking copies,
<br /> ° Al Cpry 7lit . 3 "
<br /> f. Markan (X) in the box next to tite item that best describes the reason the form Is being catnpletett.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> F. 77ANK D&SCRIF17I'Il'u-COMPIX17IA.11,rlTi S-HI UNKNOWN- )SPI -7IFY
<br /> A. Indicate owners tank ID # -If there is a tank number that is exsect by the owner to identify the tank(ex,AB70789).
<br /> 13. Indicate the name of the;e company that manufactured the tank(ex.ACME TANK A1f'C"s.).
<br /> C". Indicate the year the tank was installed (ex.1997).
<br /> D. Indicate the tank capa6ty in gallons (ex.25,0 00 or 10,000 etc.).
<br /> 11, TANK(X) fI I°°Itl'I i
<br /> A, 1. If MOTOR A_OVEHICLE E rl IFL,check box:I and complete items L3 C;. ,y
<br /> 1 If not 't'O T"OR�JI:IITCLE I t ld, check the appropriate box in section A and compl:te items 13 T)°
<br /> I3. (',heck the appropriate box
<br /> C'. Check k the Type of :M(-', ,6) Vl 111(11"s FUEL L(if box "I is checked in zA),
<br /> , Print the chemical nam-a of the haxat lour substance stored in the tank and the C.A.S.#. (Chemical Abstract Service
<br /> numbei), if Igor I is NOT checked in A,
<br /> LT£. -JANK h:'fC _r `I:"LCa ,.MAIRK ONE Bearl ONIX IN BOX A,B,c&D
<br /> 3. Check oniv on.. ocna in 1 T' ' 0s SYS"-F'M,'f'ANK MATERIAL, 11 I I'°RIOR I,I dINGT arm CORRO I oN I3ROTFIC 100',
<br /> IV, PIPING INFORIsCA110N
<br /> h Circle A if above gto: ads circle (I if underground;and circle both if applicable,
<br /> I, If 3^:K'NOArrN,circle or :I°O ITFI ,print in space pro-vi ed.
<br /> 3, Indicate the T,(1t LI1,I "(71ON ssstern(s)used to comply with the monitoring requirement for the piping,
<br /> V, TANK IF-A&DFnMzCI`f0N
<br /> 1. andel atc Ine, L 'Ata IST l FC-11 ?, y to n,(i) €sed to comply with the monitoring requirements for the tank,
<br /> I. INFORMNIION C"N TAANK`f III( JA IENILY CII OSED IN PLACIi
<br /> 1. S INIA'1"I I3 I1. 'I'l:i: LAST USED - MONTII/YF'A 2(January, 1988 or 07,/88}.
<br /> 2, IfS"1`l°klrA'I`ED CeiyraaYI II: of HAZARDOUS SUBST ANCT' remaining in the tank(in Gallons),
<br /> 1 WASTANK FILLED WITH IN11HP F M A`ERL,' L'7 Check 'Yes'or'NO',
<br /> PPI.IC AN'r MUSr SIGN AND D A`IT,'I7lii IX) S I DI(WIT'l).
<br /> T,n state un�a °g r,ae,. sto .' , tank id trrtfaca aom nurnber is composed of the two digit county number, the three digit jurisdiction
<br /> number, the six di,rt fadlity aurn,,)cr and the six digit oink number, The county and jurisdiction number-,are predetermined and
<br /> craw be obtained,wed ba c f in:r he state Board (916)7,19,.2431. The facility number roust be the sante as shown in farm"A". The
<br /> tank member may be assigned by the local agency; however, this number trust be numerical and cannot contain an alphabet, If
<br /> The its>cr"al agency prwfem the StK+t""*e board ,,c: assign flack tank number,please leave it blank.
<br /> rr IS'ITIF RH SI0NE—I1III:X OF'1.1 A L.,'A"kC LA(:lEN(')'71TA 'INSP C"IN 1717 F r . I'Y'M VERIFY 1111?
<br /> rAC(4I:R A(IY O[I I LIE INI? IIkMA'I C3 . '"I"III:I()C AI, (ll l°4(:Y IS ILEASI"ON Sl 11.13 I?CI 'I'F I:T RTI I`[C) ()la't'he:
<br /> "I 0CAL AGENCY USE ONLY*I F ORINIV11ON 13K)X ANDC)IC FORWARDING ING ON FOR 'A'AND ASSOCINITD
<br /> I A:lF2 SII(sa' O 411E,FOLLOWING I)F;tRESS.
<br /> ST '1"1r OF CALIFORNIA
<br /> 91 F I I: '4 Y a RES{IIIL(IrS(X)Nl°ROL I)I)ARD
<br /> C`;%(a,ev( It-1_4P.S.
<br /> DATA
<br /> g I' I)C1LSS1 sC C"f i�I l$I
<br /> P.(1. Ifsyx!127 -
<br /> AR 1OIT L, %9
<br />
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