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1N,(;1'R.UC`1I0NS FOR CUMPU.NING IW)RM,ir
<br /> GENERAL INSTRUC:1710NS-
<br /> L One FORIM "13'shall be completed for each tank for all NEW PERM-TI'S,P11"RIMrr(TL,\NGF-1;,
<br /> other 1ANK INFORMNITON CIIANGF-
<br /> 2, 'I'his form should be completed by either the PERwr APPLICANT or the LOCAL AGPNCY UNDERGROUNDTANK
<br /> IPI SP M, 70R.
<br /> 3. Please tyre: ,r print clearly all requested information.
<br /> 4Use a hard point writing instrument,you are making 3 copies,
<br /> 'FOP OF FORM: 'MARK ONLY ONI.i.rll-.M*
<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.DJ-7SCRIPI7ON-COMP11TIT All.r179SLS-IF UNKNOWN-SO SPECIFY
<br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank (ex, AB7,0789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME4 TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1.987).
<br /> D. Indicate the tank capacity in gallons(ex.15,000 or 10,000 etc.).
<br /> 11. TANK COMITININ
<br /> A. 1. If MO-.0R.VEHICLE FUE,.L,check box I and complete items B & C.
<br /> 2. If not ,,.0170R VEHICLE FUEL,check the appropriate box in section A and complete items 13 & 1),
<br /> B. Check the appropriate box.
<br /> C. Check the type of mo,rOR 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 CA.S.#. (Chemical Abstract Service
<br /> number), if box 1 is NOT checked in A.
<br /> III, TANK CON,1;rRUcnON-MARK ONE r1-EM ONLY IN BOX A, B,C&D
<br /> 1. Check only one item in TYPE OF SYSTI.,"WFANK MATERIAL, lN`I'ERIOR LINING and CORROSION PROTEC1,10N.
<br /> 1 If OTHEA,print in the space provided.
<br /> IV. PIPING IN17ORMATTON
<br /> 1. Circle A'If above ground: circle U if underground: and circle both if applicable,
<br /> 1 If UNK1\C,,,WN,circle; or if GTIIER,print in space provided,
<br /> 3. Indicate LEAK Fal 1J'L(.,T1ON system(s) used to comply with the monitoring requirement for Ibc piping,
<br /> V. TANK LEAK.DUITU-11ON
<br /> 1. Indicate the LEAK D1,."H..`,CI'ION system(s) used to comply with the monitoring requirements for the tank.
<br /> VI. INIzORM)VI.IONO,,,V'I'ANKPf-,RMANI.N[I.Y(.7.,OSI�3INPIACI:I,
<br /> 1. I-SFINIXY1.71)DA'I'S 1ASTUSED-MONIJI/NEAR(January, 1988 or 01/88).
<br /> 2. QUAIVITI I Y of HA/ARDOUS SUBSJANCF remaining in the tank (in Gallons).
<br /> 3. WAS TAINK FILLED WrIll INT.,'IRTNIXIERIAL? Check'Yes'or'NO'.
<br /> Appuutmr MUST'SIGN AND DA71,711111 FORM AS INDICA11111
<br /> IN,1;rRUCIION FOR111H LOCALAGI-INCIFS
<br /> '17fie state undo-rground storage tank identification number is composed of the two digit county number, the three digit jarkdioion
<br /> number, the sl-,� digit facility number and the six digit tank- number. The county and jurisdiction numbers, are predetei nt��ncd t)nd
<br /> can be obtaincJ by calling the State Board(916)739-242'1. The facility number must be the same as shown in Form 'A". Tle
<br /> tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an alphatict. f;
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> rI'IS'1IIE RF-1SPON.SIBI1.nY OF IIIE LOCAL AGENCY IIIA717 INSPFC`1`5 771E FACIIXITIX)VERIFY11IF
<br /> A(,'(-IJRACYOI'IlflilNFORMNIION. ITIS?LOCAL AGENCY IS RE-STONSIBIJi FOR'11111131 C OMPI E[ION OF 4111
<br /> *LOCAL AG%I.!,NCY USE ONLY*INFORMA71TON BOX AND FOR FORWARDING ONE FORM*A"AND ASS,0c1A'n1,D
<br /> FORM-Ir(s)TO T111E R)LLOWING ADDRESS.
<br /> 917NIV,OF CALIFORNIA
<br /> SI`IE WA711W Rl-.SOUR(-'I!-S C'ONT'ROL BOARD
<br /> C/o 1&WJ-1Kj-1.S.
<br /> I)XI'A PROCV&SING CI,1*N1IT.R
<br /> P.O.BOX 527
<br /> PARAMOU11TI',CA 9(rM
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