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INI�I`RUCIIONS FOR COMPLCNG F0119'
<br /> GENERAL I' IJC.I`1ON%-
<br /> L One FORM"Ir shall be completed for each tank for all NTrW PE N PERMUCHANGFA REMOVATS and/tar any
<br /> otherTANK C)It "110NI ("IIANGTL
<br /> 1 This form should be cc mnicted by either the PI,7RMrr I C', I'€ar the Lo I.AGENCY UNDER(3ROUNDTANK
<br /> INS aF 'C)TL
<br /> 3 Please type or print clearly all requested information.
<br /> 4: Uses hard,plaint writing instrument,you are making 3 copies.
<br /> 'FOP C)Ir 1N) : "MARK ONLY ONE ITEIM'
<br /> 1e Mark an (X)to the box next !m the hem that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or Paciiity name where the tank is installed.
<br /> 1, TANK DFISC; t S'Ic7N-(X) PI Xl l F AIJ,TTI' S--IIt U C) N- S I
<br /> A. Indicate owners tank 1 )# -If these is a tank cumber that is used by the owner to identify the tank (ex,A1370789),
<br /> I3, Indicate:the name of 0he company Haat manufactured the tank(ex.ACME°T'1xNK MFG,).
<br /> C., Indicate,the year the tank seas installed,(ex, 1987),
<br /> D. Indicate the tank capacity in gallons(ex,25, or 10,000 etc.).
<br /> 11.. TANK C N"ITWI4
<br /> A. L If MC)FOR VEHICLE I Ul," ,check box 1 and complete items B& t'.
<br /> 1 If not NIOTOR V1,1111CLf",IA,I,L,check the appropriate box in section A and complete itches 13& D3
<br /> B. (.heck the appropriate box,
<br /> C, Check the type€>€ N-10TO `EIRC[s- FUEL(if box 1 is checked in A).
<br /> D, Print-The chemical name of the ha<a do€as substance stored in the tank and the C,A.S. .(Chemical Abstract Service
<br /> number),if box I is NOT checked in A,
<br /> III. "TANK C0N,5I' i1C'I`If)N-MARK ONE,1`11M ONhY IN BOX A,B,G&I)
<br /> 1.. (heck only one item iia TYPE 01 S STJ'M,'TANK MATERIAL, IIS IERIOR LINING and f;C)RROSIf3T`°«I'ttOT C CION,
<br /> 1 If OT I2,print in the space providcd,
<br /> IV. PIPING INMRMATION
<br /> 1. Circle A if above ground,circle'L1 if underground;and circle both if applicable.
<br /> 2, If UNKNOWN,circle; or if OTIIURz print in space provided.
<br /> 3. Indicate the L, K I?ETI-'1C'1'I0N-sy-,tcm(s)used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DEIT(71710N
<br /> 1. Indicate the:IlIDNK I7Ll"t k:C,I"7C N systern(s) used to comply with the monitoring requirements for the tank.
<br /> VL INIX)RMMION ON TANK PERMANENNX C`T..GS €1-TN PLAM
<br /> 2 F'"t`IMA :I3,Dt'k'[`I- IAAF t SEI)-MONrl-ll/Yl.,Att(January, 1988 or 6'(/88).
<br /> 2. 1",STIMAT D QUANITFY of HAZARDOUS OUS SUB51ANCE remaining in the tank (€n Gallons).
<br /> 3. WAS TANK FILLED WITH IIN13Irl'MATERIAL? Check'Yes'or'NO':
<br /> App (` - I'MUW SIGN ANT)ISA"III 11TV FORM AS INDICNIED.
<br /> TNSI'IC,t1C"I`I()N FOR'1111E LOCAL AGENCIP-S
<br /> "lilac state underground storage tank identification number is composed of the two digit county-number, the three digit jurisdiction
<br /> number, the six digit facility slumber and the six digit tank number. 'rhe county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2425. 'Fhe facility number must be the same as shown in form"bre. The
<br /> tank number may be assigned by the; kval agen y; 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 /> PI°IS UHI RUSPC)NSI UXI"° OF'nIE LOCAL AGENC14 II I'INSi'I ., N UIE FAC TI, ID ERII°f TUE
<br /> ACCURACY C) TfII?INFORMA71ION. `111F IX)(AL AGENCY IS RESPONSIBLEI'C)II 11111 COMPUMON OF'I`IIE
<br /> ' ..AGENCY TSI .)DILLY*INMRMJVJ10N 13OX AND FOR FORWARDING ONE MRM`A' 7 ,% Cl1 1`ED
<br /> M 'IP(s)TO 11113 t 011,()W NG ADDRESS.
<br /> I'A°I°t,, WNITIR R SOU C�'IN CONI'ROL BOARD
<br /> C/o S;W.1?I?I".s.
<br /> D 1°A PROCU:SSING MN I`Iil
<br /> P.O.BOX 527
<br /> PARAMOUNI7,CA 90723
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