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<br /> I.NS-17C_7CI ION (,C) I"1aFI'. Ca FORMW
<br /> L One FORM M„B,„shall be completed for each tarok for all NTW.. PERWIN,PERWI'(11ANGUS, 12Ia 1C7VA S and/or any
<br /> 2. This forr€t should be completed by either the 11-ERM " 1*T"L,1CANI'or the 1,00U,AGENCY FJPVDEi1CsIt.0 UND TANK
<br /> SPIT'N'01$`_`1
<br /> 1 Please a.yv or print clearly all €equest(d information,
<br /> 4Use a heard pont w=hall;;in",,h,rurscmd'°you are, making l copies,
<br /> TOP 01?FORW',MAURK ONLY ONE Mlw
<br /> 1. Mark all (X)in the box next to the item that best describes the reason the form is beirc.6"completed.
<br /> . Indicate the DBA or Facility name where the tank is installed.
<br /> . TANK DESC IIP1'1"Cl i-a)MPI.r_l All,11'E N S-1 T UNKNOWN-4f)SPECIFY
<br /> A. Indic°ale owners tank ID # -If there is a tank number that is used by than owner to identity the tank(ex,AB707,5 ).
<br /> Ti, lndra,mc the na€nc,of;fire company that manufactured the tank (ex.MCMI"J'ANK MIT .
<br /> C, Indicate- the year the tank-was installed (ex. 1987).
<br /> . Indicate the tank capacity in gallons(ex.25,000 or 10,(KK)ctc.).
<br /> A. 1. If SICI'I`OR VEHI, I,E l UT'lL,check laox I and complete items B& C'.
<br /> 2. If Trot MOTOR°1 E1110J,"FCi;i,,check the appropriate,box in section A and complete items 13 & D.
<br /> ClC'hccl< the appropriate box.
<br /> h€ck ibe typc of MOTOR VEHICLE h't%El,(if box I is checked in A).
<br /> I1. Prnit t,:,chcFr cap n;mra of th in the tank slid the C°,-r,S.#. (Chemical Abstract Service
<br /> num if ..a l ,,: ` ` cTeckcd in,
<br /> Ili. 'TANK MWUK I i'�I.r1l,"M ONLY IN hW,)X A, 11,C&IS
<br /> 1, ('heck,. :l; yaw .tb sr ,s 1 C'1 at S 1,`l,; S MATERIAL, IN I'f:1RIOR LINING and (,",O ROSION FpliOT C 1100.
<br /> 2, If C 111-A, z r "t in rn pace la o €dead.
<br /> IV, 1"11"ING INIrORMA 1IC:N
<br /> 1. Circle A if above ground„ circle U if undergronnd; and circle both if applicable.
<br /> 2, If ici,clf; car if C)`I"?IE=,I print in pace Iatcavi<3cd
<br /> '; �'?I .
<br /> l,"dio..e the 'LEAK each to comply with the monitoring requirement for the piping
<br /> V. 'WANX I,I'YA 1I5 €I.'C"#.Ir`';N
<br /> I, lndic,,etc oic LF=y : c(u)used to comply with the monitoring requirements for the tank
<br /> V), INFORNIA7110N ONTalNK PERMAISHMILY CLOSE,))IN PLACE
<br /> 1. i'SUt%4 ATI I'll) DXYL I AS I`USED-:x 8iN I/y'FAR(,January, 1988 or 01/88).
<br /> 1 E,'sII%.INI"Illi (.}1JANl'1"Ia�`"of HAZARDOUS SUBS'EANC:E?remaining in the; tank(in Gmlons).
<br /> 1 AS'1't N FILLED b'r`WITH INEIZT yiAJ IaIUAL't Check'es'or'NO'.
<br /> a PPF_I 'r ' 1ISI°SIGN AND I)A.1 i.1 I1�FORM AS F 7FC `I U).
<br /> 'Ilse state underground v-o age tank- idendfication Psinber is composed of the two digit corsnty number, the three digit jurisdiction
<br /> number, the s;x dig t i j.aat_ty number and the sax digit tank number, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by r,al€;nye .he-State Board (916)759-3421. The facility number must be the same as shown in farm "A,'. The
<br /> tank nunibee l may be assig€ed by the i a d agency; Inywever, this number must be numerical and cannot contain an alphabet. If
<br /> the ,area! ay =c 'pka err; the State fc sir;$ to assign the lank number,please leave it plank.
<br /> IT I ''EI11 RUSPONSiiili_.E'I°Y OF°111E LOCAL AGC"Y°THAT I SPIX71 v 1711I 1WILI'i'Y'lu VERIFY
<br /> ACX'1 RA Y OF711H 11H I IRMA l`0N. 111E WCAL d Cali C.'Y IS RISPONSIBIJ.W FOR11111 COMPLE7,110N OFUIE
<br /> "IX)CAL AGEWY, GEEUSE ONLY'I IOF1 I701d 13OX AND FOR Ik)RWAI2DING ON FORM*A*AND ASSOCINIED
<br /> F ORM11,(s) ,1111^:IaCIUU:a '1lrili ADDRENS,
<br /> yi X1 {;VIA11HR Fli*S0Ia11C CCS C'Cihd'1"ICC`IL 1101 1
<br /> D.A17% PROCESSING t'1 tFaTI?R
<br /> 1pO,BOX527
<br /> $
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