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i <br /> aIN4;MUCHONS FOR COMPLETING 011111 <br /> 1„ BOW" �l$ae ipie d fere`ea a n Beall `PER 1 CI AI and/or any <br /> other"T TION CHANG& <br /> "I This form should be completed by either the PERMr.r APPUCAN17 or the LOCAL AGENCY E RGRO T <br /> INSPECrOR. <br /> 3a , Please t 'sar print clearly all requested information, <br /> 4. Use a hard point,writing instrument,you art rtrakitig 3 copies. <br /> TIOP CIS FORM..-MARK ONLY OW, I <br /> 1, ,Ma&an(X)in the box next to the iters that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank isinstalled. <br /> I. TANK DEscRIMON 1 L T[ S-1111INKNOWN <br /> A, Indicate a eta tank 1I ; -i there is a tak'rtirer that is d try the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.AC [F TA:N FG' ), <br /> C. Indicate,the year the tank. 's installed(ex. 19f1'7)., <br /> D. Indicate the tank capacity in gallons(ex. . , or~10, etc.), <br /> H. TANK <br /> A. 1. If MOTOR VEHICLF E1,1,check box 1 and complete items B C. <br /> 2.if not MOTOR VM11CLE FUEL,check the appropriate box in section.A and complete items B&D. , <br /> B. Check the appropriate riate box, <br /> C. Check the type of Mtn°I'OR t S-iI ,lE IUEL(if box 1 is checked in A). <br /> D? print.the chemical name of the hazardous substance,stored;an„ (Chemical Abstract Service <br /> number),if box I is I OT checked in A. <br /> EII.'TANK C O O -MARK ONE IT04 ONLY IN BOX A,II, <br /> 1. Check only one nein in' P I '.VI,`I°APv`1C T ATERIAL, IN71'ERIOR LINING and CORROSION PROTFC 71,14_N. <br /> .i If OT EP,print in the space provided. <br /> IV. PIPING INIX)RMATION <br /> 1. Circle"A if above ground,circle'U ifundeIrground,,and circle both if Applicable. <br /> 2.' If UNKNOWN,circle; or if OTIIF ,p'rin't in space provided. <br /> .` Indicate the LEAK DE11KNION sgster (s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETEC110N <br /> 1. Indicate the LEAK d7FTEC711ON system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMAMON ON TANK PERMANEN11Y CLOSED IN PLACE <br /> 1. ESTIMATED DA".171 LAST USEO- O I/ R(January, 1988 or 01/88). <br /> 2. MIMA"I'ED QUANTITY ITY of IIAZARDOVS SUBSIANCE remaining in the tank(in Gallons). <br /> 3. WAS;TAMIL 11 LLED WrITI INE ILIAL?Check'Yes'or'NO'. <br /> APPUCANr MUST SIGN ANDIlA"t; TILT:FORM AS ".A`1'ICJ. <br /> IN1,5MUC11ON FOR111111 LOCAL AGENCMS <br /> The 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 tie State Board(910)739-2421. The facility number must be the same as shown in form"A. The <br /> tank number may be assigned by the lineal agency;however,this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Board to assign the hank number,please leave it blank. <br /> 11T IS IM RESPONSIBRI17Y CII THE LOCALA€s -1 THX1'INSPW,1*.S'I1IE FACILITYTO VERIFY`IIII? <br /> C 'Y CIp 11 -iO 110N. "i ACII f"Y 1S SII3 1I R IT I O I ON 01"IME <br /> -LOCAL ACpNCy LSF INFORMAMON BOX AND R DING O `A!AND ASSOCIATED <br /> MRM"I"(s)TO°I IE?FO11,OWING ADIDRES& <br /> 5rNl'E OF CAL(FORNIA,i <br /> SrATE WN17ERRMSOURCES COMROL BOARD <br /> DATA PRCKIMING <br /> P.O.BOX 52'7 <br /> PARAMOUNT, <br />