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INS'FR T: C)NS MR COMPLLMNG Ill "IIS <br /> GINERAL INSFRUCITONS- <br /> 1. One FO "13"shall be completed for each tank for all NFW PERAU17S,PERMIT(11ANGES, R? C) AI and/or any <br /> other TANK IR '1 C)N 01ANC`sIT <br /> 2. This fortis should be completed by either the PERWr APPU(ANr or the I.( I>AGENCY UNDERGROIJNDTANK <br /> INSPI.CrOR- <br /> 3. Please type or priest clearly all requested in <br /> 4. Use a hard point writin instrument, esu; re <br /> Maki 3 copies, a.y <br /> � �• .1 esug. e <br /> TOP OF F RR ONLY ONE ISI : " <br /> 1. Mark an (]C)in the box next to the item that best describes the reason the forret is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> . TA I)1_ 6' '4 I. .. . .r AE,Z .. 5-lit C) -< t <br /> AIndicate owners tank IF) #-If theie,is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the name of the-company that(naanufactured the tank p(ex.ACME TANK MFG.). <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 /> 11. TANK C O z t S <br /> A. 1. If 11JC)'L`OR VF11ICL FUI.iI-,check box F and complete Items B tic C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items FI& 17. <br /> B. Check the appropriate box. <br /> C. Check the type of MC)'F`OR VEHICLE FUEL(if box I is checked in A). <br /> I). Print the chemical name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Sct Ice <br /> number),if box 1 is NOT checked in A. <br /> III, TANK C ON917RUC FION®MARK C) ..<riijm C) . :Y IN Box A,F�C&I) <br /> 1. Check only one item in TYPE C)I^S'YSrL ,TANk MATERIAL, INTERIOR LINING and CORROSION F'IRC)`I1'(77110N. <br /> 2. If 0111ER,print in the space provided. <br /> I 4 PIPING. FC?R TIC)IY <br /> 1. Circle A if above;ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,R,print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to,comply with the monitoring requirement for the piping. <br /> V. TANK IMAK DI-IFEC"110N <br /> 1. Indicate the LEAK I)F`.TX,'iION system(s)used to-comply with the monitoring requirements for the tank: <br /> V1. INFORMAIION ONTANK 1'I NEaN11 Y(I.CISE"D IN PIACli <br /> 1. E.S11;11t TESD DATT.L,ASI'USL I)-MONFII/YEIAR(January, 1988 or 01/88). <br /> 2. F?SrIMA`I'ED C)UAMITI'Y of IIA7".ARL)t:)US SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TAMC FLI,L,110 W17111 INE)IT MAT?IiIAI,? Check`Yes'car'NC)' <br /> APPI..IC `musr SIC3N ANF)Djula,'1°w FORM AS INDIC.A`I '). <br /> INsTRUC HON I R TIII?LOCAI,AGENCHiS <br /> The 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 sire digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shower inform "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 /> r ISTIIE? )NSIB 1"Y OF'111E LOCAL AGENCY 111ATINSPECIN TIIE FBA.(31XI°Y"'1'0 VERIFY11TE <br /> ACCURACY Cm"Y C)F II1i INBORMATION. 111E LOCAL AGENCY IS 110SPONSIBLE FOR 11113 C() I'I,F?"11C)N 011 11TE <br /> *LOCAI.AGI: CY USE ONLY'INIX)RMN170N BOX AND FOR FORWARDING ONE FOR 'A"AN13 A.S.° 1 11) <br /> FORM "(s)IY)111E FOLLOWING ADDRESS. <br /> SIrY OF CA11FORNIA <br /> S"A'I':i WKI'ER RESOURCES CDNTROL BOARD <br /> CIO . .IL Ips. <br /> DATA PROCOSSING C ENIIrR <br /> P.O.BOX 527 <br /> A �. <br /> r <br /> 4064$( . <br />