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IN!iI`ItU(NIO S FOR£"tTMPI I SING Ty)I£.
<br /> GEN VI AL 111'RE"( 1ONS;
<br /> 1, One IaOR "II"shall be conipleted for each hank for all NEW P17RM 1 S,F�IffiI? I FFt1 CiF�s, I3 C I_S and any
<br /> otharTANK INI70RMA`I10N1CHANGE
<br /> 2, This form should be completed by either the PERMI ° PIX.: ';ll or the I LOCAL AGEN(-Y UNDERGROUNDTANK.
<br /> INSII "I'£3II
<br /> ;3, please tyke or print clearly all requested information.
<br /> 4. "`Uses bard point writing tCnstrumcnt,you are making 3 copies.
<br /> "I'OP OF F . 'MARK ONLY£I II ry,Fm,
<br /> 1, Mark an (X) in the ,;fix next to the .;vasa hat best describes the reason the form is being completed.
<br /> 2. Indicate ttte htE,'t cr Far tl.r.y mutt 1vite e the tank is installed,
<br /> L TANK 130XMIYI`T.C) £°CI I t,I1:i1It 1,L I't°EMS-IF UNKNOWN-,So SPI-4:0FY
<br /> . Indicate owners tank lD C`e If the rt,is a tank number that is used by the owner to identify the hank(ex.A13713789).
<br /> B. Indicate the na9n4 of the co-Irsoo,that ntanufacucrMd the tank (ex.AC= E,JAN MFG),
<br /> G),
<br /> C, Intficate the.year th and rs s imoafacd (ex 1987')-
<br /> 1),
<br /> 87).1). Indicate th,.tank c.,i acdy in galtr.ns(c ."-15,000 or 10,000 etc.),
<br /> IL TANK£:C?l�ITNI >
<br /> & L If 1+1(11`€R vI II?t TI r"f11 L,check box I tied c,:riplete items II R C;.
<br /> I°n«t SIC)ff)I1 .?,tlIt,a,I.T I L, check tiro appropriate box in section A and complete items B & T3.
<br /> . Check the aprropr u- bre
<br /> C;, Check the type of MOTOR V FI 11yTE FUEL I (it;tax 1 is checked in A).
<br /> , faint the tmemical name of the hazardous subsoince;stored in the task and the C.A.S, ,(Chemical Abstract Service
<br /> number),if boy 1 €s NOT checked in A,
<br /> IIT. TANK C: 1'RUC °I£) -MARK oNu rrum oN, IN BOX A,FI,td&I3
<br /> 1. Check only one item it TYPE OF SYS^T'ai:t1,"T'r`C."a'IC"I?kT RIAL, IT^i`IU IC)11 LINING and CORROSION PROTla.C710N.
<br /> 2, if fl TTI B,pot in the space provided.
<br /> IV. PIPING lNItORM 1I 3
<br /> t. Circle A if above grit ccaa, circk, U if underground; and circle froth if applicable.
<br /> 2. If UNKNOWN, circle; or if 011114t,print in space provided.
<br /> 3. Indicate the I,Ex a.>I<`II,C,I'I°I°x systcm(s)used to co€stplSw$th:the monitoring requirement for the piping,
<br /> V. TANK 11-AK DUITXXION
<br /> 1.. Indicate the; LF',AK p�;`T'It,C'Id£3'N system(s)used to co'rnply with the monitoring rcgeaire;iients fe>r the tank.
<br /> INFORMA`1710N O TANK PERMANIINIIX CLOSED IN PLACE,
<br /> 1. F SiIMAII:i)Tirels: LASS 1SSI,l)- I I I/Y AIC(January, 1998 ot-01/89).
<br /> 2. I1STI . 1 d)C)T.,r NN ITY of 11ZAp.DO S SC BS IANC p: remaining fit the tank (in Gallons).
<br /> 3. WAS'1`ANK FILLED WITH INERT MATERIAL? Check''yes'or',NO'.
<br /> r1PP11£AIaI'SIGN AND 11NI"FT 1111 F()RM AS IN IC "I`T I3.
<br /> INSFRU(NION p'C) 'I'FII3 LOCAL AGENCHVS
<br /> The state underground storage lack identification ncarnber is composed of the two digit county number,the three digit jurisdiction
<br /> number,the six digit f ae ii;y number and the six digit tank nurnbe°,r. The courry Land jurisdiction numbers are predetermined and
<br /> can lie obtained by calling the State Boa (91(x)739-2421. `a` e facility number must tic the same as shown in farm"A', The
<br /> tank number may be assigned by ilia local agency, however, this number must be numerical and cannot contain an alphabet. if
<br /> the local agency;prefers the State hoard to assign the tank number, please leave it blank,
<br /> rl'IS IIID RF;SPONSIBIIXI' 01i'1111,F.,CIC:, L AGITl9£ '',I I 'I'I dSPIX IS`IIID FAC IITO VE IIIF Y'I'IFIx
<br /> AC( C' OF 1-111, INFORMATION. a"II ,£3C L GFNC`l IS RliSPONSIBLE,FoRTIIEOMPuThON Cala TIII:;
<br /> 'LO I,AOUNt FJSZT ONLY"INFORMATION IX)X AND FOR FORWARDING£1a` E Ir£)2 -A-AND ARSOCIX110
<br /> FORIM "(x)_ -111E p' 1d 0WING ADDRESS.
<br /> 'T a'l'l;OF C., ,I1Ik)F I
<br /> 11sr 1 wivn,,R RFT.4£1tIII£:' I 'I`RO BOARD
<br /> c/O S. _ e
<br /> DXJ Ix€FC:A("E&SING (7EW1"F F£
<br /> 0,BOX 527
<br />
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