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GENERAL S'I UC 1'IO <br /> 1. One ISG "I3"shall be completed for each tank for all NEW PERMYIN,PER ,rr CIIANGrLS, REMOVAIS and/or any <br /> other TANK INFORMA31ON Cat NG " <br /> 2. This formshould be completed by either the ISE , tT AppucAlsrr or the I A)CAL AGENCY UNDERGROUND 17ANK <br /> I SPE <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a hard p�oian Wxitin instr ae yo q snaking 3 copses. <br /> Its"'�x8*;„” <br /> TOP OF FORM:'?AARK 014i.Y ONE ITIN' <br /> 1. Mark an (3C)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 /> NXII <br /> L TANK I)i- .TC��I�._., ;. PI.,t? s ALL r.ES-IIr UN C) -SO SPHCJFY <br /> A. Indicate owners tank I -If the rJs a tank number that is used by the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name of the company thaitirnanufactured the talc (ex.ACME TANKIv FG.). <br /> C. Indicate the year the tank was installed(ex.'1987). a <br /> 13. Indicate the tank capacity in gallons(ex.25,000 or 10,0W etc.).: <br /> 11. TANK COI�MW]17S <br /> A. 1.If MOTOR VFIIIC LI FUEL,check box I and complete items 13&C. <br /> 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items l3& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). <br /> 1). 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 /> IT. TANK C ON91'RUCIION m MARK ONE nEm om Y°IN Box A,II,C& I3 <br /> 1. Check only one item in TYPE 01'SYSFEM,TAINKMATERIAL,INTERIOR LINING and CORROSION PR(yI`E(-.7I0N. <br /> 2. If OTHER,,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if 0-111ER, print in space provided. <br /> 3. Indicate the LEAK I)F:I'EC.71 ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK taI?'I'EIKA'1'10N <br /> 1. Indicate the LEAK DFI`ECTION system(s)used to comply with the:monitoring requirements for the tank. <br /> I. INFORMATION T° PE NEN17 (1,09q)IN PIACE <br /> 1. E'S`TIMATED DATE I.ASI:'USED-1v1C?NITI/Y AI2(January; 1988 or 01/88). <br /> 2. F.SI'IMATUT)QUANIT Y of IIAfAR .US UBS-FANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLE'D W I INERT I X`.€F-,k2iAL7 Check'Yes'or'a'O% <br /> APPLIC° Sr SIGN AND DMID'I.TIt FORM AS I I)IC N I ). <br /> NS RUC'I7t)I9 FOR 11 IE LOCALAGE C Is:S <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 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 /> rr IS TT 3 )NsiBuxi, E`3tl'i"III?t E ACI z. C,'Y"IIIA'I'INSPE I T'III1 I?A(3f,rI'Y'I'O t?r2I 'I IE <br /> ACCURACY OF17113 INFORMATION. '11113 LOCAL AGII'NC Y IS SPONSII3t.t?FO TI III?(C) PI I3'l.`IC) C)I$11111 <br /> *I to AGENCY USE ONLY'INFORMATION AT'ION I1O I)FOR FO WARDi1 G ONE FOR *A"AND ASSOCIN17ED <br /> FORM-W(s)TO t I LOWINGI DRI—,SS. <br /> STNI 3 OF CALIFORNIA <br /> SrA'I'E WKI'FR ESC)r:lttt NJ` )t BOARD <br /> C/O S.W.r?RP.Sa <br /> DMIA PROC'ES.SING(7 MR <br /> P.O5 <br /> 96* <br /> PAR I <br /> <...,...... <br /> i <br /> R <br />