Laserfiche WebLink
INM�CCIONS VOR,COW1EMG'#M'Ir <br /> 1. <br /> One FORM vir hall�be e O for'ea t tank r all i CILWGM REMOVAL and/or any <br /> oilier TANK l,LCAT CIIANGE, <br /> This form should be completed by either the PERM., APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <br /> INSPECTOR. <br /> 3. Please t, or pant deerly all, quested inibimatlian. <br /> 4. Use a rd point itin iftxtrutnent,you are making 3 copies. <br /> TOP OF ILS.ONLY O a I <br /> 1. Mark an (X)in the box'next to the item that best'describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> Indicate owners tank IIS#w If there is a tank rmtnber that is,,used by the,,owncr to identify the tank(ex.AI3V789). <br /> Bt Indicate the name of the company that manufactured the tank(ex.ACME TA IC FG.). <br /> C. Indicate the year the tank-was installed(ex. 1%'7). <br /> . <br /> D. Indicate the tank capacity in gallons(ex. 5, Qr 121, etc.). <br /> IL TANK CONTENTS <br /> i <br /> A. I,If MOTOR VEHICLE FUEL,check box 1 and complete items 11&C <br /> 1 If not MOTOR VEHICLE FUIEL,check the appropriate box in section A and complete items 11 D. <br /> B. k the appropriate box. <br /> C. Check the type of MOTOR VEIRC;I, EL(if box 1 is checked in A), <br /> I3, print the chemical name of the l azard6us substance stored in,tiZn•.,t .k.arch he .h. . .(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> TANK u o _mARK ONE,rLEm ONLY IN BOX A, <br /> 1. Check only one item in TYPE O :I ,`t'ANKIA" E'RIAL,IN,I'E RIOR LINING and CORROSION I'ROT C`1710N. <br /> 2. If C3`I'HER,print in the space provided.'' <br /> IV. PIPING IN14ORMATION <br /> 1, Circle A if above ground`,circle U if underground,and circle both if applicable. <br /> 2. If UNKNOWN,circle,or if CD IEE,print in space provided. <br /> 3. Indicate the LEAK I1F ,C; ION systern(s)used to comply with the monitoring requirement for the piping. <br /> V. TAMC LEAK I I"TON <br /> 1. Indicate the LEAK DET E(711CIN system(s) used to comply with the monitoring requirements for the tank. <br /> nON f1ATTANK PIMMANENITA CLOSED IN PLACE <br /> 1. ESTIMATED DATE IAST USED-MO I/YEAla(January, 1988 or 01/88). <br /> 2. FSTIMIAIED QUANTITY of MkZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WASTANK 14,LLEL3 WMI INERT T X "ItlAL?Check'Yes'or'NO'. <br /> APPLICAlIff MUSM SIGN AND DATR*111E FORM AS INDICATED. <br /> IN,15MLFCTION FORT1411 LOCAL AG C°I <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 number, The county and jurisdiction numbers are predetermined and y <br /> can be obtained by calling the State Board(915)739-2921. The facility number must be the same as shown in form'A". The <br /> tank number may be assi aed 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 /> IT IS ITIE RESPONSEBRXI'YOF THE LOCAL AGENCIf 11WIANSPECIN'TIIE F C;IL TO '111E <br /> ACCURAC—Y OF 1111?IN14ORMATION. `I II? ACZI�NC' IS RESPONSIBLE R 111 LO OF°['1111 <br /> *I' � AGENCYUSE ) O BOX� ANIS FOR It DING ONE I %A`AND ASSOCIATED <br /> FORM 0111(s)T017113, f T G ADD <br /> I <br /> SEK111 CIS CALIFORMA <br /> TA NIE U C 4S CONIMOL'BOARD <br /> /CI S," .S. <br /> DATA PROCESSING LES. <br /> 1';CI.BOX'527 <br /> L3I T�CA 90723 <br />