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INST'RUC17IONS MR COMPLETING I `I#* <br /> GENEXAL t'RUC TIONS <br /> 1. One FORM"Et"shall be completed for each tank for all NEW lPI? I.'S,PER rr CHANGFIS, Rya OV I s and/or any <br /> other TANK INFORMATION(311 IG <br /> 2. This form should be completed by either the P I I APP r or the LO I.AGENCY UNDERGROUND TANK <br /> INSPEC Rm 3. Please type or print clearly all requested information, <br /> 4. Use a hard pottywriting instrup,ct u- %e making e,Cspies. ,, <br /> �y <br /> v . <br /> 1`01?Of FORM. "MARK ONLY ONE M.W <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 I) ICs 6Mmum,AI i s n II*uN o) -so I? <br /> A. Indicate owners tank ID # m If the�c is a tank number that is used by the owner to identify the tank(ex.A B70789). <br /> B. Indicate the name of the company thatImanufactured the to)41-(ex.ACMETANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). � <br /> D. Indicate the tank capacity in gallons(ex.25,OW or 10, etc.). <br /> 11. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE £'L;EL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL,L,,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of ltIC3TOR VEHICLE FUEL(if box I is checked in A'J <br /> 9). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.r1.S. . (Chemical Abstract S t vicc <br /> number),if box 1 is NOT checked in A. <br /> TIL. TANK C.O SrR1 BC"ITOhd-MARK ONE TIPONLY IN BOX A,I3,C.°&D <br /> 1. Check only one item in TYPE OFSYSIUM,TANK'M.'t°I'I`s1 RAL, pI"I:?I2IOR LINING and CORROSION PRO"IT',( 1710N. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIP RM ITON <br /> 1. Circle At.if above ground; circle I:I if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,.print in space provided. <br /> 3. Indicate the LEAK I)EsI-E ON systems) used to comply with the monitoring requirement for the piping. <br /> V. 'YANK LEAK 1)I?i pcnO <br /> 1. Indicate the LEAK DF-,71T-.(,MON system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION owrANK PER Ise nY C"Dsua)IN PtAcm <br /> 1. f,. 'IT-ITI I)ATI I.Absr USI I)-MONTII/YEAR(January,2988 or 01/88). <br /> 2. FS17IMATEI3 QUANTITY of IIA7AI2I)OIJS SUBSTANCE remaining in the tank.(in Gallons). <br /> 3. WAS TANK FILLED WITH 1NEI;VF MATERIAL?Check'Yes'or WO'. <br /> A VPL1 ST`SIGN ANT)T K111 TIl I?FORM AS INDIC-NIFD. <br /> ST RUC'110N 1 R VIII? i.AGENCIES <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 six 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 mast 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 /> TI'Is um REsPoNsiBiury OF 171111 I OC'AL AGENCY'IIIA T INSPf I 'TIII3 FA0I 1 T`O VERA `11111 <br /> ACCURACY Y CBIS TIIH IidfOR `1'ON, THE I.0)C`.AI,AGE,, C IS —SPO 5111111 FOR 11113 C°.O PI.,TTION 017 1I1I1 <br /> "I I.AGf24CY USE ONLY"INFORMN11ON BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIA110 <br /> ISR "13"(s)1.0"17113 F01.1,0WING A DDRI;SS. <br /> S•I'NI'I?OF C I,IFOR IA <br /> gTA7`I3 WATER RFSOURCIN CONTROL BOARD <br /> CPEO S.W.F I?P.S. <br /> I)NFA PR. ?S SING,0 ITtR <br /> P.O.BOX 527 <br /> ` „ PARAMOUkT. <br />