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Aft <br /> IN';mucnONS FOR COWUMNG <br /> CI t. L I ISI°It O - <br /> One T .* r;shy beconipleW, fad cash tnak,f0, all PES I` REMOVALS anti/or any <br /> witherTANK C) Iw? <br /> . "Phis form should be completed by eztYter the W 1PP C', °or the LOCAL AGENCY )TANK <br /> I SP - <br /> 3. T�1 t or ristt eIearly°all zettested itsfo aticin: <br /> 4. L7se "hard <br /> point zs rititt9 inst nt, a are makingcopies, <br /> TOP. "MARK Y ON1311 " <br /> L Mark ah(X)in the box next to the item that bestd ribcs the reason the farm is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANX DESCRIMON-OOMPLUM,AILL UEMS IF ITSPECIFY <br /> A. Indicate o ers!tank TIS Tf I ercjs a tan,number that*,used by the owner to identify the tank(ek.AB70799); <br /> . Indicate the name of the company that manufactured the.tank(ex,ACINAE TANK.Mme.), <br /> Indicate the year the tarot wasinstalled(ex, 1987 <br /> Iia Indicate the tank capacity in gallons(ex,25,000 or 10,000etc j.' <br /> II. TANK CONTPNfS <br /> A. 1,If MOTOR VEP[ICLE FUEL,check box 1 and complete items 11 C, <br /> 2.If not MOTOR HICL FUEL,check the appropriate box in section A'and complete items B&D. <br /> T1s Check the appropriate box. <br /> C. Check the f of 5t3IC31 IIICLL '" U(if box 1 is checked in A). <br /> D. Print the chemical nameof the hazardous"substance wed in„C�e�t 'kram� �C �S :��Claem #Abstract Service <br /> number),if box 1 is NOT checked in An <br /> III. rANK cowrwcnoN-mARK ONE mm,owy IN Box A, C&I <br /> L Check only one'stem in` Pl�OF SYSTEM,TANK MATERIAL,IN ^RIOR LINING and CORROSION I'i2OTEC 1710N. <br /> 2, If C)TIF8P,print in the space provided. <br /> . PIMG ORMATION <br /> 1. Circle A if,above,ground,; circle U if and x ounds and circle both if applicable: <br /> 1 1f UNKNOWN,circle ar it OTII ,p'rmt in space provided. <br /> Indicate the LIM DEITICTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAR DE17ECTION <br /> L Indicate the LEAK DEI' C:'I"ION system(s) used to comply with the monitoring requirements for the tank. <br /> VL 'I`ON ON TANK PERMANEM.11M CLOSED IN PLACE <br /> 1, ESUMATED DATE LAST USED-IAC) VYEAI2(January,1988 or 01/$8), <br /> , ESTI A,TFI)QU.AN""T`"l'Y of I DOUS' T T`A'ME remaming in the tank(in Gallons). <br /> 3. WAS'k lal TC ILL ED CII I F�'I'M a RIAI?Check'Yes'or'NO'. <br /> APPIJCANr mun siaN AND DATE,- CC S <br /> UC CIN FOR 11IR LOCALAGENCIES <br /> e state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction <br /> number,the sax 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 its form'9Al. The <br /> tank number may be assigned 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 /> P['IS THE RESPONSEBUMF AG CY 111X1'INSPEC`M,'11IEFACMXff TO VERIFY THE <br /> ACCURACY OF ITIE`"TIEIhl `IC1 . ITS LOCAL AGFN(-'Y IS RESPONSIBLE FOR.117113,CGMPIHnON OF I°IIIT <br /> OLOCAL AGENCYUSE ONLY"INFORMA110N BOX ANDFOR FORWARDING ONE FURM"A"AND ASSOCIAIED <br /> FORM OW(s)TO 1`11E FOW)WING ADDRFM. <br /> SIATE WATER RESOURCM9 COMROL BOARD <br /> C/o&W + <br /> DX A PROCIMUNG tC <br /> P i 27 <br /> PARAMOUNI7,CA <br />