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AL <br /> INSI"RUC"ITONS FOR COMPIP,11N( ,AM"13° <br /> GENERAL IDIS•. UC 11 <br /> } . One E`C1RJM"L3"shall be completed for each tank for all NI, HR IS,PI3 TT L:II GR%, 1811CIV S and/or any <br /> other . I7ON CTI G <br /> 2. "T'his'form sboutdobc completed by either the PFRMrr APPLICANT or the LOCAL ACH.'INCY UNDERGROUND'IANK <br /> INSPEC110R. <br /> 3. Please type or print clearly all ,requested information: <br /> 4 Use a hard point writing instrument,you are making 3 copiesa <br /> t $ < <br /> L C>IR OF K)M-'MARK ONLY ONE TIEM' <br /> 1. bark an(X)in the box next to the item that best describes the reason the form is bei s completed. <br /> 2: Indicate the 4 Facility name where the tank is installed. <br /> I. TANK &SC RIFIIC) z,COMPIEfE All,r1T.W,3-1I?UNKNOWN m SO SPECIFY <br /> A. Indicate owners tank ID#- If there is a tangy number that is used by the owner to identify the tank(ex.A1370789). <br /> I3. Indicate the name of the company that manufactured the tank(ex.ACME TANK °C,,). <br /> C. Indicate the year the:tank was installed(ex.'1987). <br /> I5. Indicate the tank capacity in gallons(ex.25,000 or 10 000 etc.). <br /> 11. TANK CONIIINTS <br /> A, L If MOTOR VTI-IIC.,i FUT.,[,,check bdk'f and eonfplete items B& C. <br /> 2.If not MOTOR VEHICLE IaL;EL,check the appropriate box in section A and complete items B& D. <br /> T3. Check the appropriate box. <br /> C. Check the type of Mfl'I'OR VEE-11C LE 3`1J1 L(if box l is checked in fi), <br /> 13. Print the chemical name of the hazardous substance stored in the tank and the C;A.S. .(Chemical Abstract Senice <br /> number),if box I is NOT checked in A <br /> 111. TANK CONS UC HON-MARK ONE TI-1,24 ONLY 136A,11,C✓°&13 <br /> 1. Check only one'stem in TYPE OF SYSTI M,"T°ANK MATERIAL,INrrERIOR LINING and CORROSION P18C)T CI'If)N. <br /> 2. If cyriTE ,priest in the space provided. <br /> IV. PIPING INFORMNITON <br /> 1, Circle A if above ground; circle U if underground;and circle beth if applicable. <br /> 2. If UNKNOWN,circle:or if 011TER,print in space provided. <br /> 3. Indicate the LFAK I-A ITIC7,1`ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK Df?`FVCI1O <br /> 1- Indicate the LPA D I§I CTION system(s)used to comply with the monitoring requirements for the tank. <br /> V1. INFORMN110N'ONTANK PERMANEIVITM C %Wsly IN PI. C1> <br /> 1,. TF:STIM '1ED L3 'I'I"LASTUSED-MCJ: III/Y AR(January,1989 or 01/88). <br /> 2. EFFI4iA`IED QUAN'1` r Y of iIA7A1CDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAST4NKTILLED WITH I I s`PT MN TESTAL`P Check'Yes'or'No '. <br /> PPLicANr JS'f'SIGN AND DA MI'11H 17ORM AS I DIC.A113D, <br /> The slate 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 <br /> can be obtained by calling the State Board (9]6)739-2421. The facility number crust be the same as shown in form "A". 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 /> I°I`LS 11111 RIM)NIN13111IT OF°111IJ LOCAL AL AC.iI: 'IIIXI'I SPIE I'S'I`[lfi F 01,1` 'I'Cl VERWY 111E <br /> ACCURACY OF 111111 INFORMN110N. 'III LOCAL AGENCY IS RISS NSIBLE FOR 111,C OMPI;I:LION 0171711i <br /> 01A)C: L ACP C;Y USE ONLY'11SWORMN17ION BOX AND IiOR FORWARDINGONE FORM*.A"AND A&SOCIA7110 <br /> FOR "13'(s)TO 1111:1701JOWING AVDRI%S . <br /> XIM f3 -I t <br /> t <br /> 91'NI 3 kV11?Lt RINOIJIOONI'ROL BOARD <br /> c,/O S. ". ,I? s. <br /> P.O.BOX 527 ,pv <br /> A °MC3UNI',CA S„_ <br />