Laserfiche WebLink
AOL <br /> IN I"RIJ . O S FOR COMPLEnNG FORMW <br /> Gl.NHRAL rRUC 1ON <br /> L One FORM"IB"shall be completed for each Lank for all NFW PE I. ,PES TI'CI GFS, REMOVAI.S and/or any <br /> other TANK INFORMATION TICI GIAb7CT <br /> 2: This form should be completed by either the PElitma APPUCANr or the LOC.AI,AGIINCY UNDERCAROUNDTANK <br /> 1 SPIT R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> OF FORM- ONLY€NIt rrEM <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I_ TANK DIS "R' IC) -C~"CI mE? ,Au rmms-TIA uNKNowN-so spawy <br /> A. Indicate owners tank ID # -If there is a,tank number that is used by the owner to identify the tank(ex.AB70"7A9). <br /> I3. Indicate the name"of the company that manufactured the tank(ex,ACME TANK M Cl.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.).` <br /> If. TANK CONn.Imn <br /> A. L If MOTOR VEIIICLI: FUE1.check bears 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items iB& D - <br /> iB. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box l is checked in A). <br /> 11 Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> IIT. TANK C ONgrRUC"IION-mARK Qh1E?rrum ONLY IN 13OA,13,C:&D <br /> 1.. Check only one item in TYPE O SYSIT.M,TANKFATE'RIAL,INTERIOR LINING ING and CORROSION PRO'FE;CIION. <br /> 2. If OTHEI? print in the space provided. <br /> 1 'IPING INFORMATION <br /> 1. Circle A if above ground;circle II if underground;and circle tooth if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided, <br /> 3. Indicate the LEAK DE'FECTION system(s) used to comply with the monitoring;requirement for the piping;. <br /> V. TANK LFAK Dff1`ECFION <br /> L Indicate the LEAK 1 EI ON system(s) used to comply with the monitoring requirements for the tank: <br /> SIL INFORMATION ON TANK PRRMANENFLY CLOSED IN PL C.'1,? <br /> 1. EST11MATED DATE I,AS'I'USED a MON1..1III/ `I AR (January, 1988 or 01/138). <br /> 2. ESTIMATED QUA r1"ITY of SIA ARI'}OUS SUBSTANCE remaining in the tank(in Callous). <br /> 3. WAS TANK FILLED WITII INEWI'MATE?RIAL" Check'Yes'or'NO'. <br /> AF'PHC 'MUITr SIGN AND IBA'I'I?11111 FORM AS INDIC NI'El). <br /> INS'F UC HO POR'111E LOCAL AGE C:IC, <br /> I:'he state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction <br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and i <br /> can be obtained by calling the State Board(9I6)739-2421, The facility number must be the same as shown in form "A". The <br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT ISTHLI R N%Ii3I I'Y 01:111-111 IMAL AGENCY"I1IAT'ItiSI'Ea,C4I',S 11111 IIACHnym V13RIFY71111 <br /> ACCURACY C Y 011 TIIH INFORMATION. 171E LOCAL ACAIi C Y IS RESPONS111111 FO 'ITIS C,CmPi,I?'nON OF 11111 <br /> 'LOCAL AGENCY USF ON '1M?ORMX110N BOX AND FOR FORWARDING 0141i FORM'A"AND ASSO(71AIED <br /> FORM-I3"(s)T01711:1 ISI J O ICIDRI3 ,S. <br /> S `11 71€air CA1,111ORNIA <br /> SEKIU WATER x i:IRCIS C'CI 'RCTI BOARD <br /> C/O s t li.P.S. <br /> DIVER PROC:< SING CI= ITR <br /> P.O.PDX 527 <br />