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INSNIR C I"IO S)POR C"CTWTIMC1 FOR -
<br /> GENERAL,1N"I`RLTC-OO SSs
<br /> 1, One FOR 'IT"shall be completed for each tank for all NEW PFRWIN, PER r `CHANGES, REMOVAI.S and/or any
<br /> other'IANK INFOR.MMION C1 A GE
<br /> 2. This foam should be completed by either the 1PffRMT1`AP11I,1CAmr or the wC.AL AGENCY UNDERGROUNDTANK
<br /> INSPEM'OR.
<br /> 2, Please type or pert clearly all requested information.
<br /> 4. Use a Lard 1,oint:varltirtg instrument,kora are making 3,copies.
<br /> F?,ORM, � AR'R ONLY 11TEP f
<br /> i Mark an (X)it,, .he,box ext era the stens that hevt•describes the reason the form is Facing completed.
<br /> 2, Indicate she DBA or laacn ty ncnte where the tank is installed,
<br /> L TANK DESCRIMON-CCF 111.,11`lfI'Al T'IEMS-IF UNKNOWN-SO SPECIFY
<br /> A. Indicate ?,kne s I nk 112# -If there,is a tank number Haat is used by the owner to identify.ihe tank(ex. t1.B`70789).
<br /> FI. Indae:aate the,narric c the coxcl>anY that manufactured the lank (M AC.'E"I'ANK MFG).
<br /> C. la ate &ac g tank, was int=,a,,d fee, tpd'
<br /> 1::. `n,kczaz tate,tancl capacio,,in galions (cx,25, or 10,0(X')ctc.)�
<br /> It. TANK(X)N Idtta
<br /> A, L UMOTOR s r JI hI a E'l,,check box 1;and rnrrplcte items 13&C.
<br /> act MOTORVIE1,TICIT.FUEL, cheek The appropriate box bisection A and complete items 13& D"
<br /> B. (,"heek ?e alTnopriale box,
<br /> C h s, e la G;R VF111C I t FUEL�l t (if box 1 is checked in A).
<br /> 1a, pr.�.>the cbcmical name of the hnra?dous,sulrsttance, stored in the tank and the C..A.S. .(Chenaical_Abstract Service
<br /> s.Y.nlcrl, if?roz ? as .`r(3 s checked as A.
<br /> ITT. TANK C,ONS°T RIJCMIO I,iA K ONT,, 1711M ONLY IN RoX A, I,C:&1)
<br /> L C,heck on1v one itcsea inTYPE OY SYS'MK'1`ANK M.:"IERIAL, 1l71'ERIOR I:ILI G anis CORROSION I'fZCI"f'EX710N.
<br /> 2. If 01,1I1"'k,Print in the space providcd.
<br /> I . PI I C.I I F R N11ON
<br /> 1. C,Irc!c A if above crc,asr.d circle U..1'undergroa n(L slid circle both if applicable,
<br /> 2 If UNK.NOWN, ci , orif()TH1,,b,,pTint in spat, provided,
<br /> 3. Ind icat. the LI'LLS Lass 1ZC"I`tlyN system(-)used to comply with the monitoring requirement for the piping;.
<br /> 1, Inchcate the l,l`,>R trS>`I l;C'I"l i of tea i.>, used ra comply with the monitoring requirements for the tank.
<br /> VI. I IFOI?P A°ZION ONTANK I�Ii'IRMAItiEI I`LY C10SITD MT PLACE
<br /> T. I St"IM li(. L)liI:F, ,I"L;SIa, a 1TC3:k:'"IIOYFAIZ (January, 1988 or 07/88).
<br /> 2, F-S11itf_'kaaT) 01,_L'k"1,I.1.1.of IIA7_LRI)OL;S SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS`A K T"ILLED WITH INI,RT IYIATER L,? Chea k'Yes' or'NO'.
<br /> APPIJCA. 7'11J I'SIGN AND IJA'I1,11rFS FORM AS IC T .
<br /> #N',-I"RL.'•(.I`ION FORTUE,1:C1f. I> nLI CI1
<br /> "los: .>we urldl rgrc uRd storage tank identification number is comp(,)ccd of the two digit county number,the three digit jurisdiction
<br /> nUraaber,the sot d g.fc h=y rlulrnLer and 'he six digit tante arrunbe,r. The county and jurisdiction numbers are predetermined and
<br /> can be obt<ainc t b,,,cafling the State Board(936)739-2421 'Fbc facility number must be the sank as shown in form'A". "1'he
<br /> tans nurnber may be assigned yy,the ,ocai agency; however,this number must be-numerical and cannot contain an alphabet. 1f°
<br /> the local Igency prefers the F4ate 1lcaacd to assign the tank number,please leave~it blank,
<br /> H'IS T'IIF,RESPONSIBI1XIT Iaa'111R JX)CAL AGENCY' A"I"T S S'11 3 RAC°I '10 VERIFY ME
<br /> C(__3JRA,C: O '111IT INITM4XI10N. '171F3 LOCAL AGENCY IS RESPONSIBLE ICJ MIM COMPIEFITON O 11IIa
<br /> *LO(W,AGE., C"Y USE ONLY''1 I :r xnO IM AND FOR FORWARDING ONE MRM'A'AND a14SSO(,IKMzD
<br /> FR -W s)'rc)TI II'F OI,1 CT1V IN AD REM.
<br /> S1ATI,OF CA1,11a"O ItS
<br /> NIA:Iii, A'I-I,R RItSOURCT I S t T`RO BOARD
<br /> C/o SD f13sIr.I1 R�S
<br /> IIA°CA PROCE&SING C,F, IT"R
<br /> P,O,BOX 527
<br /> PARA IC:)UNTU CA WM
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