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INSMUCIIONS FOR compu7nNG � <br /> GENBRAL'INSTRUCHONS6 <br /> 1, One FO " shelfbe comp Let �for each tankl6i�ali �[ and/or any <br /> other' A IO CI-1ANGF— <br /> L This form should be completedby,,either.them4tWr APP, Uc or the w. AI, t"s C;Y 1INDERGROUN13TAW <br /> INSPVC,MR <br /> 1, Please t*or print clearly all"retlues ed informaticui. <br /> 4. Use a hard point writing instrument,you ark making 3 copies. <br /> I OF ONLY ONE 111W <br /> 1« Mack an <br /> (X)in the box text to the item khat best describesthe reason the form is being completed, <br /> 2, Indicate the DBA or Facility name where the tank is installed. <br /> Al Indicate owners tank W -If there is a tank number that is used by the owner to identify the tank.(ex.AB-7"9). <br /> 8. Indicate the name of the company that manufactured the tank(ex,ACME I'ANKI MFG). <br /> C. Indicate the year the tank was installed(ex. 19n., <br /> fD. Indicate the tank capacity in gallons(ex,25,000 or 110,000 etc,), <br /> IL TANK I <br /> A. 1.If MOTOR VEHICLE FUEL,'check box 1 and cornplete items F3&C. <br /> .If not MOTOR VEMICLE FUEL,cheek the appropriate box in titan and complete items 13& D. <br /> R. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLEL(if box 1 is checked in A)• <br /> D. Print the chemical name of the hazardous substance stored trl,ln�tank ° (Chemical Abstract Sesvice <br /> number),if box T is NOT checked in A, <br /> III. TANK CoNgLRUCTION-MARK ONE MW ONLY IN BOX A,'I C <br /> 1, Check only one item in TYPE OF SYSIVM,TANK MNIERIAL,Ili -III it LINING and CORROSION PROTEC"1C3N. . <br /> 1 If OTHER,print in the space provided. <br /> IV. PIPING INPORNIATION <br /> 1. Circle A if above round';circle U itun r rouad;and circle both if ap licable. <br /> 2.' If UNKNOWN,circle; car if 01.11EIL,print in space provided. <br /> 3. Indicate the LEAK I3 , ;C:I'LON system(s) used to comply with the monitoring requirement for the wiping, <br /> V. TANK LEAKI)HITZHON <br /> L Indicate the LFAIC ISI ,' C `1ONy system(s) used to comply with the monitoring requirements for the tank. <br /> 1, Fff.11MATED DATELAST DATEUSED-MCI I/YEAS (January,1988 or 01/88). <br /> 1 ESTIMATED QUANTITY of HAZARDOUS SUH91"ANI C remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED,wall INEit°I' RIAL?Chec 'Yes'or'NO'. <br /> APPI1CANr MUSTSIGN AND DWIINDICAIIID <br /> IN1,TMUC11ON FOR111B LOCAL AG <br /> 'Die 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(910)739-2421, The facility number mast be the same as shown in form"A". The <br /> tank number may be assigned by the dual 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 /> 13'IS THE RF—SPONSE3HXFY OFTHEAGENCY °I"F �TIM E'AC,1 °I THE <br /> ACCURACY t3E THE INFORMA110N. 11 AC"xltl IS RESPONSIBLE R T 11E MPI C? OF THE <br /> t x (J °ONLY"INFORMATION � AND FOR FORWARDING ONP FORM W AND ASSOCIATED <br /> FORM-W(s)'M-111E VOI-IA)WING ADDRESS. <br /> STXMT OF CALIPORNIA <br /> SIATE WAIMR RESOURCES CONI'ROL <br /> /o SmILF-Ps. <br /> P.O.BOX S2? <br /> PARAMOUNT, <br /> ., . QL <br />