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AM 1r
<br /> INSTMUC110INS FOR COMPLMING *
<br /> CTI NEWAL INSTRUM71ONS-
<br /> 1. One FOI2M, "13' shell be completed for each tank for all NFW PFR ,PnRm.rr CHANGES, RFMOVATS and/or any
<br /> otherTANK IMlORMN1100 CHANG&
<br /> 2, This form should be completed by either the PER MTTAPP11CAM17 or the LOCAI.AGENCY UNDERGROUM)TANK
<br /> INSPIN7ft)k
<br /> 3, !lease type or print clearly all requested information.
<br /> A. Use a hard point writing instrument,you are making 3 copies.
<br /> ,VOP OF F()RM: 'MARK ONLY ONii unm"
<br /> -k, l the item that best describes the reason the form is being completed.
<br /> 1, .Met m X) in the box next t(
<br /> 2. Indicate the DBA or Facility name where the tank is installed,
<br /> T. TANK 1305CRIV110N-compu.,rili AjL Ti-tims-Ill uNxNowN-So inictiry
<br /> A. Indicate owners task 11)# ®If there is a tank number that is used by the owner to identify the tank(ex,AB70789),
<br /> B. Indicate the name of the company that manufactured the tank(ex.AC.ME,"TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1987),
<br /> 1). Indicate the tank capacity in gallons (ex,25,000 or 1.0,000 etc.).
<br /> H. TANK CONn-,,MlN
<br /> A, i- if mar-OR Vi.,,IIICI,F FUE'L,check box I and complete items B& C.
<br /> 2, If not MOTOR VEIIICI,1"1"U'17L,check the appropriate box in section A and complete items B& D.
<br /> IT Check the appropriate box.
<br /> U Check the type of MOTOR VEHICLE FUEL(if box I is checked in A).
<br /> D. Print the cbernical name of the hazardous substance stored in the,tank and the C,A.S,#. (Chemical Abstract Scmice
<br /> number),if box I is-NOT checked in A,
<br /> 111. TANK C OM511TUC'TION-MARK ONE nim ONLY IN BOX A,B,C&D
<br /> I. Check only one itern inTYPF',Cif?SYST.EWFANK MzVI'ERJAL, INTERIOR LINING and CORROSION PROTFCIION
<br /> 2, If OTHEk,print in the space provided.
<br /> Its. PIPING INFORMJVIIO
<br /> 1. Circle A,if above ground; circle U if underground;and circle both if applicable,
<br /> 2, If UNKNOWN, circle; or if 011MR,print in space provided,
<br /> 3. Indicate the LEAK LSI qT'1C`'I0N a C cut for fie piping.
<br /> I ystcm(s) used to comply with the monitoring requir m t p ping'
<br /> V. TANK LITAK DTnTfC1TON
<br /> I. Indicate the IJ..-iAK DFIT"C'11ON systern(s) used to comply with the monitoring requirements for the tank.
<br /> V INFORMA11ON ON TANK PERMANEN11M CLOWID IN PLACE
<br /> L E&FIMATED D/V11.11' IAST USED-MO\,T]-[I/YMR(January, 1988 or 0-1/88).
<br /> 2. nsTIMATFI) QUANT11Y of IIAZARDOUS SUBSTANCE remaining in the tank- (in Gallons).
<br /> 1 WAS TANK Fql,l FD WTI I I INERT MATER L? ("heck 'Yes' or'NO',
<br /> APPI1CAN7F`MUST'SIGN AND D/V1V'I1TF,FORM AS INDICK11311
<br /> 1NS1-RU(7nON F)DR 11 1E LOCAL AGIN, 00S
<br /> The state underground storage tank identification number is compowd of the two digit county number, the three,digit jurisdiction
<br /> number, thesix 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(91.6)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 mnst be numerical and cannot contain an alphabet. If
<br /> the local agency prefer-,the State Board to assign the tank number, please leave it blank.
<br /> r.p1S'I1TFi RESP ONSIBlIXI'Y 0FnIE LO(AL AGIfNC`Y 111K['INSPIX71"i'll IE FAC 1,MTO,VERIFY TITE
<br /> ACCURACY OF 11T INF` THE LOCAL AGENCY IS RESPONSIBLE 17ORTHE COMP1.117ON OFTHE
<br /> 'LOCAL AGENCU,4
<br /> Y I ONLY'INFORMA`nON PDX AND FOR FORWARDw ING ONE 110i;� AND ASSOaxtED
<br /> FORM'B"(s)TO'HIF,F(HIDWING ADDRIM.
<br /> 917NFIr OF CAJIFORNIA
<br /> RISVIT',WA`11.ilk RESOURCI.S COMI'ROL PA)ARD
<br /> C/o Smi-1,11P.s.
<br /> DNIA PROCMSING CENVER
<br /> P.OOX 527
<br /> PARAMOVNI',CA 9(YM
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