|
!NFVRU(.'I10NS FOR CO-VIYUNING SRM—137
<br /> GENERAL lN,1MRU('110NTS-
<br /> 1- One FORM W shall be completed for each tank for all N.IV, PERMTVS�PF R!Arf-CIIJNNGES, RF,M(',V,J�urld/--m,,
<br /> other TANK INFORMATION CHANGF-
<br /> 1 This form should be completed by either the PFRWFAPPUCANT or the LOCAL A(311,N(W UNDERGROUND FANK
<br /> INSPFX-7R)tL
<br /> 3, Please I%Te -,,.r print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies,
<br /> 'FOP OF FORM:- *MARK ONLY OW rll-,M*
<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 /> I. TANK DEN MWVIION-COMPlIT113 AU.rI13M3-IF UNKNOWN-SO SPFX-1IPy
<br /> A. Indicate owners tank ID # -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.ACME TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.).
<br /> 11. 'TANK CONYn.Wn'
<br /> A. 'L if MO-t"R VEHICLE FUEL.check box I and complete items B &C.
<br /> 2. If not ,°.,JTOR VI IIICLE FUII-L,check the appropriate box in section A and complete items 13& 1).
<br /> B. Check the appropriate box.
<br /> C. Check the.type of MOTOR VEHICLE FUEL(if box I is checked in A).
<br /> 1). Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service
<br /> number), if box I is NOT checked in A.
<br /> 111. 'TANK.CONSq`RUC1`1ON-MARK ONE 17171-W ONLY IN 11OX/-,13,C&D
<br /> 1. Check only one item in`TYPE;OFSYS1L-'M.TANK MATERIAL,INTEI.RIOR LINING and CORROSION PRO'l FV'110N.
<br /> 2. If 07111E.0,print in the space provided.
<br /> TV. PIPING INMRMA11ON
<br /> L Circle A it-dbonv ground, circle JJ if underground: and circle both if applicable.
<br /> 2, If UWNT'�WN,circle; or if OTHER,print in space provided.
<br /> 3. Indicatett=P LEAK DE'TECITON system(s) used to comply with the monitoring reqwi-cmew for the piping,
<br /> V. 'TANK 111AK,DITIT�f'IION
<br /> L Indicate LEAK I.A.."'TEC11ON system(s) used to comply with the monitoring requirements fol,the tank,
<br /> VI. INITRNIA11ON OI TANK PfiRMANIN11M C1..OSUD IN PtACZ
<br /> 1. 1`.M'VW,!T7D DA`f`E 1AS`FUSFD-MONTII/YEAR(January, 1988 or 0l/SS).
<br /> 2. ESHMATUD QUANTITVY of HAZARDOUS SUBSTANCE;remaining in the tank(in Gallons),
<br /> 3. WAS TANK FILLED WITIT INERT VkXIERIAL? Check'Yes' or'NO'.
<br /> APPucAmr MUS-17SICAN AND DAT111111-1 FORM AS INDICNIVIX
<br /> INS-FRUCLION FOR TUB LOCAL AG11NCIlN
<br /> The state und(�r-round storage tank identification number is composed of the two digit county number, the three diuit jurisdiction
<br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction number-,are predetermined and
<br /> can be obtainc�; by calling the State Board (916)739-2421. The facility number must be the same as shown in form 'A". The
<br /> .nay number ay be assigned by the local agency; however,this number must be numerical and cannot contain an alphatict. If
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank-
<br /> rI'IS'1J1L1 RJ�SIIIONSIHIIXI"Y OF 771E LOCAL AGFNCY 11INFINSPECTI'SITIE FAC11,117V110 VERIFY TTIV
<br /> ACCURACY OF TITE INFORMA7110N, 11111 I.00AL AGENCY IS RESPONSIBIX,FOR'1111.�COMPI13I1ON OF THE
<br /> *LOCAL AGENCY USE ONLY*INFORMATION 1"X.AND FOR MRWARDING ONE*.FORM`A*AND ASSOCTA7171)
<br /> FORM-B-(s)TO TUIE 17011,OWING ADDRESS,
<br /> STATE OF CAUFORNIA
<br /> SEN117 WXIVR RE-SOURCKS CONFROL BOARD
<br /> C/o S.W.I&I.I.Ps.
<br /> DATA PJ>,0C1TSS1NG CTNIVR
<br /> P,O.BOX 527
<br /> PARAMOUNT7,CA 90723
<br />
|