Laserfiche WebLink
IN9I`II, T . CS S MR COMPLEIING 11ORM Ir <br /> GINERAL . r C 11ONS- <br /> 1. One FORM"F3"shall be completed for each tank for allto I.°S,PERMrr CIIANGUS, REMOVAUS and/or any <br /> other TANK INMRMAI.ION CHANGE <br /> 2. This to.rm should be completed by either the Ing I Appuawr or the LOCAL AGENCY UNDERGROUND TA <br /> SI'I1 <br /> ..- 3. Please type or print clearly all requested information, <br /> A. fJse a hard point�ritininsRruzint,yu e anakan 3co ' s. <br /> P?p ....p <br /> �' , ". <br /> TOP OF : ONIM ONE II :r .", <br /> 1. Marl:an (X)in the box newt 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 /> L TANK DF �id -' M PI ,ALL nims-tP uNKNowNa so smoff <br /> A. Indicate owners tank IIS # - If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name cif the company that manufactured the to k(ex.ACME,'TANK MFG.). <br /> C. Indicate the year the tank was installed(ex; 1987): o�w <br /> D. Indicate the tank capacity in gallons(ex.25,0€0 or 10,000 etc.). <br /> IF. TANK CONnWf.S <br /> A, 1. If MOTOR VF IIICLE p'UE.L,check box 1 and complete items B& C. <br /> 2. If not MC9'1'C R V IIICI..E FSU I,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box, <br /> C. Check the type of MOTOR VEHICLE i UEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. .(Chemical Abstract Se 1a7ce <br /> number), if box I is NOT checked in A. <br /> III. TANK C ONST tJC1TCIN-MARK ONE rlVM ONLY IN i . A,11,C&I3 <br /> 1. Check only one item in TYPE 0I'SYS'1EM,TANk,MATERIAL,INTERIOR LINING and CORROSION PROTT ., 0N. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA11ON <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DE1-1- , ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LPAK DETECITON <br /> 1. indicate the I,,F:AAIC DETI"C'TION system(s)used to comply with the monitoring requirements for the tank: <br /> VL INFORMN11bN ON TANK PlikMANENFLY C OS10 IN PLACE <br /> 1. E,VI'INFLATF i?DATF?1 AS"I'USED-MINTY!/YPAit (January, 1988 or 01/88). <br /> 2. IMATEI1 QUANTITY of IFA7A I1QUS SUBSTANCE remaining in the tank..(in Gallons), <br /> 3. WAS TANK t~'II1:E3IJ Wrrll INER T`MATEICIAI,?Check'Yes'or'NO% <br /> APPF IC° 'MUST SIGN AND D)VII:'11111 FORM AS INFiF(_`ATTI). <br /> S rRUC HON FOR1111i LOCAL AGENCH 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 trust 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 /> CI`ISTH137RESPONSIBUXI'V 01711111 LOCAL AGENCY 111 I'FNSP I'S 171H F?ACII r VF RIFiY'11IE <br /> ACCURACY CY C3l?17111 INFORMAITON. 11113 LOCAL AGI N(.'.Y IS ?SPONSIBLE?FOR111E CCIMPHi IC?N OF T1IF? <br /> *LOCAI,AGFACY USE CI Y' X)RMATION BOX AND FOR.IX)R ARDING ONE FORM W AND&%S0 C 'Dill <br /> FOR -W(s)°I`?11111 1061ING ADD US-S. <br /> 9I7MIT3 OF CAIJFORNIA <br /> STAT7>WNI' R SCI11 C 09 COMMOL BOARD <br /> C/o S. . .a p <br /> DA7FA PROC11ISSING C1Wr R <br /> P.Q BOX 527 <br /> A Mcg <br /> a <br />