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INSMUCIIONS FOR COMPI-FnNG 110M"Ir
<br /> GENERAL,I S"I'RUy 11010 »
<br /> 1, One FORM"I(" shall be completed for each tank for all NEW PFRMTIN 1 ERMIT CIIA (IRS, REMOVAILS and/or any
<br /> other TANK INFORMNI'ION CHANGEL
<br /> 1 This form should be completed by either the PERMY17 APPLIcANr or the LOCAL AGFN(.Y LfNDER IIZCIEIND`I°A I
<br /> IE Z.
<br /> ';, Please type or print clearly all requested information.
<br /> 4. Use a hard paint writing instrument,you are ma mg 3 copies.
<br /> .[CII°'Oil IA'() :-MARK ONLY C I I rime
<br /> ' I. Ntark an(X) in the box next to the it m that gest describes the reason the forni is being completed,
<br /> 2, Indicate the pti3A or Facility trarne where the tank is installed.
<br /> I. 'AN DI9 S(° IPI'IO - o mpl.I:°11I A1,,E,rl'[E -11?UNKNOW'q-,SOSPITXTFY
<br /> A. Indicate owners task 11)# -If there is a tank number that is used by the owner to identify the tank(ex.B70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME"PANIC FG,).
<br /> C, Indicate the year the tank was installed(ex, 987).
<br /> D. Indiraate the tank capacity in gallons (ex.2S�f Or 10,0etc,),
<br /> H. TAN f) Sk.`S
<br /> A� 1. If;VIt»TO 1 I;I IICI,F kL I`si, check box 1 and complete items Ii&C.
<br /> 2.If not 071'01k VEHICLE 1"LLL,check the appropriate box in section A and complete items 13& D.
<br /> 13. Check The appropriate box,
<br /> Check
<br /> the ty1x;of MOTOR C VFI IICLE'FUEL(if box 1 is checked in!a).
<br /> D. Print
<br /> chemical name of the hazardous substance shared in the tank and the C,,,,\.S. . (Chemical Abstract Service
<br /> number),if box 1 is NOTchecked in A.
<br /> III. TANK C6ONSTRUC" ( t -MARK O I?1`11W ONLY IN BOX A,13,C&I)
<br /> 1. Check only one hens in°1 YPE Or SYSTFM,'I'1'NK MiVIT"RIftL, IN'I`E'RIOR LINING and CORROSION I'ItOTF,,(7.110 .
<br /> 1 If OTHER,, print in the space provided.
<br /> IV. PIPING INIk)R ATIC)I
<br /> 1, Circle A if abcl ve ground; circle'U if underground;and circle both if applicable.
<br /> 2. If UNKNOWN, aacl or if OT]II IZ,'print in space provided.
<br /> ;I. Indicate the. LI.°:IS used to comply with the monitoring requirement fest the piping.
<br /> V. TANK LEAK DInTiC'1 TON
<br /> 1. Indicate the Ll"K D17F.C'NON ,stern(s) used to comply with the monitoring re€luiretnenis for the tank.
<br /> VI. INFORMA110N ON TANK PERMANEM11,Y CLOSEY)IN PLACE
<br /> L 1 SI'IM/VFpD UNIT TAST USED -M0YIT1/'YI;AI2 (January, 19,88 or 01/98)..`
<br /> 2. 2'I .y» s»:) C)[ ANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons),
<br /> 3, AS I°f°N 17,111,11) WH II IN ,RT MATERIAL?Check'Yes'or'NO'.
<br /> APPI,JC,: 1' JS]'S GN AN)I)XIM 1 1H R)RM AS I DIC KI`iU).
<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 numben The county and jurisdiction numbers are predetermined and
<br /> can,be obtained by calling the State Board(916)7739-2421. The facility number must be the sante as shown in form "A". The
<br /> tank nuaraber may be asogaaed 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 /> r1'IS ITIE RE SPONSE111I I"t'Y 01"17IIE?LOCAL AGT C TIIA"I'INST`TX I' `17IE i°ACaII,'Z' `1`0 VERIFY In TE
<br /> AC(1URACY OF I'IIE;
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