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INSYRUMONS MR COMPLEFING f`00R`
<br /> 1, One FOR "It"shall be completed for each tank for all MTW PER?IM'S, EMMU CF,S, REMOVAIS and/or any
<br /> otherTANK INI'(I11MYMON C:1LatNC11
<br /> 2: ",his forty should ac completed by cil her the PERM " ISPUCAN'l' xr the LOCAL AGENCY UNDERGROUNDTANK
<br /> F SITURT
<br /> 3. Please type or pont clearly all, req acswrl information.
<br /> 4. 'line a hard point uri irtg insirumceo, l,o a are making 3 copies. -
<br /> I I 01s FORM WARWARK ONLY ONE OMIV
<br /> 1, sl rk an (Il) in f l,e bot next to the itenn that best describes the reason the form is being completed.
<br /> 2. Tndicat,. the DBA-,r t`aciiitg nan;e where the tank is installed,
<br /> lled,
<br /> 1. TANK DESC RIT91O -(YDMP11i,f 11.x1..1'11.JMS- IF UNKNOWN a SO Fs`F a-7IF
<br /> A, Indicate cevners tank 11) as x ff there is a tank number that is used by the owner to identify the tank(ex.B70789).
<br /> 13, rn i ars the name of 0-(a c o?tr<,..r that r na tufaartur<° tlae tank (ex.ACMF'TANK MFG.),
<br /> (% Indicate the year the tarty. was, rn .a.,co. (ex 198�
<br /> t c,,.;atc ih,e, ark q dpa,=t> in, gaU ,s (ex, r,l,.kt f etc)
<br /> . TANK(X),N1'FE ril
<br /> A, 2, 1f TvtO'Ft:1F1'4t1d,111CLE FUEL,check.box I and cr mplcie items F3&z C.
<br /> y If not MOTOR VE'111(,11" Fd }.f, -heck the appropriate ate box in section A and complete items,B cit D.
<br /> TIS. (,,heck the appropriate box.
<br /> C`.. Check finc tope c) ;xl(:1TOR VIEl11C r I FUEL(i(box 1 is checked in A),
<br /> 1), Print tic r.3aemicar name of the hazardous substance stored in the tank and the C;`,A,FS. .(Chernical Abstract Service
<br /> numb r), if box 7 is NO I c hecke i in A.
<br /> 111, TANK C ONO 1'1FIJCTICI -MARK ONE 1"ITM ONLY ITS BOX A, F,C A F3
<br /> 1. (-neck ,,,._v cine" ate.n° in [ PE "TF SYST'1,WIAN IsT,U'U":T IAL, ExTTEIRIOR LINING and CORROSION t'f2OTFE,C:1'IOX.
<br /> 2. If OTHER,print in,no spacc provided.
<br /> IVa PIPING IId1 3 V/ F713N
<br /> 1, Circle A if abc c -routtJ,cuc=e F, if r.ndervroc=nd,and circle both if applicable,
<br /> 2, if t NY-NOWi cu'-d ,f OTHER, print in space provided,
<br /> 3. indicate the 11-t?S f?T11"11.(710'esisi ru(s) used to comply with the monitoring requirementforthe piping.
<br /> V. TANK LEAK DF717N-110N
<br /> 1, indicate the 1, "AK F I-I T.C,11O s r teras(.) used to comply with the aznnntoring requirctnents for the tank.
<br /> VI, INFORMA110N ONTANK PIFIRMANEN"I'LY MOSED UN PIACE
<br /> 1, F'Ts 11MIt" E'D D' IT"IAST USFE m M0NTH/YF'AR(January,1988 or 01/88).
<br /> 1 -',S t IMMITT) OU�.T E`ITY of I-Tt`aF��rS3IDO TS SUBSTANCE,'CE,'remaining in the tank. (in Gallons).
<br /> 3. WA T,,NN FILLED WHII 11SF',RT FNF'F:?.FCFAL? Check"Yex'crr"o'O',
<br /> PPUG N17 41 SICU AND I NIT°I"1 ?.FORIM AS INIM(SVIEly,
<br /> The state and rground storage tank nicraificatie t'lumber is composed of the two digit county number,they three digit jurisdiction
<br /> nxnrher;the six fll-it pa ility n u;nlacr and the six digit tank number, The county and jurisdiction numbers are predetermined and
<br /> can Ie obtaincd be ca!ena the Mate Board (1H6)739-242L The facility number roust be the sante as shown in form"A". The
<br /> tan"rurnite r may be ssigned by the 1«I agency; ho cvcr.this number must be numerical and cannot contain ars alphabet. If
<br /> the local agency prefeix the State.. Board to assJgn the tan number, Blease leave it blank.
<br /> I1"IS 111E 1CFISPCIIs1STFIIIII'Y CIF`1711T I.CIC 3 t GE (;''F'1IM NSI'EUD III E 1? Cr 1. _ '1'0 V F IFY'I'1F1?
<br /> ACCURMY SIF"1"111:INFORSIA1101N. THE LOCAL AGENCY IS RUSF$ONS111M MR 111E CwOMPU `FON OF''11113
<br /> "LOCAL AGENCY 1YS1E ONLY'INFORMMION BOX ANDPOR MRWARDING ONE',FOR -A" 3VS c1A'1`C:
<br /> 1�IR ' (a)r1( .T11E;M)LIDWING I DRE-SS
<br /> C .W. s.
<br /> PD,BOX 527
<br /> PARAMOUNW,CA 90723
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