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<br /> IT" TI LETT Ft .
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<br /> EL lTTI `
<br /> n 27,11 of Title 23,Division 3,Chapter 16, California Code of Regulations and sections 25266,26267,and 2'5289
<br /> d pf r 6.7,Division ,Health and Safety Code it n t f to to for T o r tin it,
<br /> I a ,. tF sa shall b completed for each tank for III PgAMIT ,FES IT I E , E -
<br /> dd/ r any otherTANK INFORMATION CHm
<br /> 2. This ft rrrtho ld b ompl t ! y either the P IT F T r I L L E I L7E
<br /> GROUND TANK I E T a,
<br /> Please type or print clearly all requested information
<br /> 4. Use,Use,a hard point writing instrument;you are rnakin
<br /> 6a Tank d n r rncr tsubmit a plot plait to the'local,a pp ;; r n d tion of the LISTS ith rd
<br /> --to buildings and.I ndmarks 12711 OO CCR),
<br /> Ta* ` �t
<br /> ments to the local agency for trrri- Ts[271 (11)
<br /> " F� :;MARK ONLY ONE ITE
<br /> I.' , rk�,, Jn k next to the item. t d rl r q.f i b ': w, .
<br /> Indito a a r Facility name where rak'I `insiai
<br /> I. T DESCRIPTIONe SPECIPt
<br /> A. Indicate owners ners tank 1 -if there is a ` k'n e t is,0 ; e,ovivnerto tdar..`x, k( .
<br /> A870789).,
<br /> B. Indicate the mists of the company that manufactured
<br /> ,,the. k(etc.ACME TANK MEW
<br /> C. Indibatetho year the Yank wag installed(ex. 19 ?`).
<br /> D. Indicate,' dk capacity in 'gallons(ex.25,000 of 1 0.00,06tc.)m
<br /> Il. TANK CONTENTS
<br /> A. 1. IF MOTOR VEHICLE FUEL,check box 1 and co I t s. ,
<br /> R If,ndtMOTOR VEHICLE FUEL,check the appr� rl to box#n 'on° and complete items D.
<br /> B. Chas, the,appropriate box.
<br /> C. Checkthe type of MOTOR VEHICLEL''(if box t Is checked i ).
<br /> D. Print the chemical name of the hazardous substance stored iii nk and the t . .#, (Chemical
<br /> Abstract Service number),if box I is NOT checked;in A.
<br /> TANK T UTI ARS ONE ITEM ONLY IN BOX, Ap ,
<br /> 1. � eq only one item in F Y TE ,T T IAL,,�I ,T I I I acid CORROSION
<br /> T T"I 1 .
<br /> 2. f OTHERj print in the space, rid
<br /> IV4 PIPING INFORMATION
<br /> A. Circle' n lf,above ground circle"Ll'if underground,And circle if applicable,`
<br /> 2, If UNKNOWN circle;or if OTHER,print in spaop provided.
<br /> . indicate the LEAK DETECTION system(s)used to,comply with the 'monitoring requirement for the piping,
<br /> V. TAF .LEAK DETECTION
<br /> 1. Indicatethe LEAK DETECTIONsystem(s) to comply with1hemonitoring requirements for the tank.
<br /> VI., I F TI ' TANK ETLY CLOSEaIN,
<br /> 1. ESTIMATED DATE LAST USED- T (January, 3 016).
<br /> 2. ESTIMATED UA TI f HAZARDOUS SUBSTANCEr malning in the tank(in Gallons).
<br /> . WAS TANK FILLED I INERT MATERIAL? Che "Y "or", o".;.
<br /> TANK OWNER OR AUTHORIZED EPR NTATIV UST SIGN AND DATE THE FORD A + INDI-
<br /> CATED [see section 2711 ( )(t )
<br /> INSTRUCTION FOR, THE LOCAL AGENCIES'
<br /> The state underground storage tank identification number is composed of the twoAiglt,county number,the three digit
<br /> jurisdiction number,the six digit facility number and the six digit tank number. The countandrisdictlon numbers are
<br /> predetermined and n be obtained by lliih the 't a (916),..' " numb r mu tbe e sa e as
<br /> Shawn in form ."thy tank number e ssigny thloi grt ,ho r,this number itst nr , and
<br /> cannot contain an alphabet. If the local agency prefers the State Board leassign the tank number,please leave it blank.
<br /> IT IS THEE6 IJ I ILI F THE LOCAL AGENCY THAT, INSPECT$ 'IMF FACILITY, T FIERI THE
<br /> RACY F THE lNFI ATI . THE LOCAL AGENCY IS OESP014SIBLE FOR THE COMPLETION OF THE
<br /> "LOCAL USE ILyaa INF TI 1 . THE, LOCAL,,AG, 61 L, . II .TIE F II ASD
<br /> YELLOW COPIES. THE,,PINK Y SHOULD, E . . ANNE °6 THE TA �. : ' E w
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