COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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UMggNS gig gp pOP yING pOgp fi i t id GENERAL IN D.1., .I.IC'H NS; 1, One FOR 1"13"shalt be completed for each tank;,for all NEW E °4,PERMrr CHANGMS, RP.MOVAIS and/or any otbe rTANK INFORMN110N CHANGE 2. This Portia should be completed by either the PFR I"APPLICAM17or the LO I,AGENCY 11 ITC"ROIL )TAN INSPECTMR. 3, please type or print clearly all requested information. " 4. Use a hard point writ ng instrument,vola are making 3 copies. -FOP OFFORM:'MARK ONLY ONEMEM 1. Nark ant ( ) in the box next to the item that best describes the reason the flame is bet ng completc;d. 2. Indicate the DBA or f=acility name cohere the tank is installed, 1. TANK M "I<ZII"nON-COMPUMi Au.1`I"III S-IF UNKNOWN-SO SPECIFY A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex. AB70789). B. Indicate the name of the company that manufactured the tank (ex.AC E TAN CPG' ). C. Indicate the year the tank�w installed(ex 11987). f). Indicate the tank capecity in galleins (ex.25,0kM or 10,000 tae.). II. TANK C°O"',N1"I A, 1, ff I (.,Y.r R VEITICLIT FUEL,clack box I and complete items B&C. 2.If not TMOTOR VE1111C IT 11"I'L,check the appropriate box in section A.and complete items B & D. B3 Greek the appropriate box. C. Check the type of MOTOR VEHIC L' t Tt,.(if box 1 is checked in A). I), Print the chcrriical scathe of the ha=ardons substance.stored in the tank and,,the C.A.S.#.(C'hentical-Abstract Service number),if box 1 is Nar checked in A, Ill. 'rANK CC)N fYRIIMION-MARK ONE rITM ONLY IN BOX A,II,C&I) 1. Check only one item inTYPE OF SYSf1177M TANLL y IT"RIA1.,, 11;SERIOR L;ININO and CORROSION PI2O ITC'I°ON. 1 If 01III*;II,print in the space provided, . PIPING IN ;I'IC)N 1. Circle A if above ground; circle C.t if underground;and circle both if applicable. 2. If UNKNOWN,circle; orif 0111111t print in space provided. 3. Indicate the LEAK used to comply with the monitoring requirement for the piping. V. TANK LEAK DMT-zCI'ION 1, indicate the LIAR DETFICTION system(s) used to comply with the ntoniforim,requirements for the tank. I IN11'C) °I"IC)N ON TA l.lR ANEUM1"i. CLOKED IN PI ('LL := ESTIMATED I)r `I'1;LAs't°t S3 t)- it I lTj t }2(3anuarv,1988 or 01/88). 2. ESTI x1 iL."D QUAN11TY QUANTITYof[IhZ,d1RD0US SUBSTANCE remaining in the tam;(in Gallons). 3. WAS`I"ANA HLLED WITH IN10'MAkNI`E'.FIAL? Check'Yes,or`NC)". APP11cANr I3,51'SIGN AND DA 1V 111F FORM AS I )IC "t'? . iNsrRumON FOR"1'fIT LOCAL AGENC IF—S `t"tae state underground steerage tank identification number is composed of the Mai digit county number, the three digit jurisdiction number,the sax digit facility number and the:six digit"tank number. Thk county and jurisdiction numbers are predetermined and can he obtained by calling the Stage Board (9"I6)739-2421. 'The facility number must be the same as shown in fortes 'A". The tank number may be assigned by the Ideal agency; however, this number trust be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it`blank. I'1°i1S'I TF R&SP NSIBI1.I"1"I"OF THF LOCAL GI "n1A`I`I PEC`M,' I MFAC1I "M RII 'nlli ACCURACY Y OF 711F INFORNNTION. JIM S LOC'r31s AGENCY IS RENP6NSIBLE FOR TIM C MPI;IMON 01711111 1I,0(:11.1..AGENCY USI' ONLY'INFORMXIION BOX AND I IxR)Ia' ARDING ONE 17OR *A'AND ASSOCIATED IaC)I 'II'()']fO'1T11I i'011,01NING ADDRESS. SME `114-R RESOURCES CON71701,BOARD CIO S. _3?I-P.;Sm P.O_TX)X 527 ' OUN'I',CA 90723