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- � <br /> � <br /> INSTRUCTIONS FOR COMPLETTN110114 °B° <br /> GENERA[ I NS[RUCTTONS: <br /> I One FOQM ^U^ shall be com0e1ed for each tank for all NEW PERNIT8, PERMIT CHANGES, REMOVALS and/or any <br /> Qher TANK INFORMATION CHANG£ <br /> 3� TMform Wild be com,leted by e1ther the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> ' INSPECTOR <br /> 3 Please ty�e or pr1nt clearly all recuested information, <br /> 4 Use a hard po1nt wrting 1nstrument, you are making 3 copies. <br /> ��P '[)F �O,","At'll: 0N[� C@� <br /> 1 Mark an (X) 1n 1he box next to the item that best describes the reason the form is being completed, <br /> 2 Ind1cate the DBA or Fac1114y name where the tank is installed, <br /> I. TANK DES(,RTPTION - COMP[ITF ALL ITEMS - IF UNKNOWN - SO SPECIFY <br /> A, Indicate ownery tank lD 4 - if there 1s a tank number that is used by the owner to identify the tank <br /> (ex AB757992 <br /> B. 00cate the name of the company that manufactured the tank (ex. ACNE TANK MFG) <br /> C I01cate the year the tank was 1nstnlled (ex, 1987) <br /> D Indncate the tanga|lons (ex 25,800 or 10.000 etc. ) <br /> TT. TAl",!K CONTENTS <br /> A. l IF MDTOR VEHICLE FUEL check box l and complete items 8 & C, <br /> 2 If not NOTOR V[HICLE FUEL check the appropriate box in section A and Complete items B & D <br /> 8Check the appro�r1ote box <br /> C Check the type of MOTOR VEHTCL[ FUEL (if box l is checked in A), <br /> O Print the chemical nome of the hazardous substance stored in the tank and the C.A.S.I. (Chemical <br /> Abmtrach Serv1oe number), 1f box l is NOT checked in A. <br /> TTT . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D <br /> I Check only onr 1tem in TYPE OF SYSTEM TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION, <br /> 2 It OTHER, Print in Lila spoce provided <br /> IV. PIPING INFORMATION <br /> l, Circle A if above ground C1rCl8 U if underground, and circle both if applicable, <br /> 2 If UNKNOWN circle: or if OTHER. print in space provided <br /> 3 Indicate the LLAK DETECTIDN system(s) used to comply with the monitoring requirement for the piping <br /> V. TANK LEAK DETECTION <br /> l Indicate the LEAK DETECTION System(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ES11100 DATE LAST UIED MONTH/YEAR (January, 1988 or 01/88) <br /> 2 ESTlMATED OUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons) <br /> J WAS TANK FILLED WTTH INERT MATERIAL? Check 'Yes' or 'NO' <br /> ' <br /> APPLICANT MOST SIGN AND DATE THE FORM AS INDICATED, <br /> INSTRUCTION FOR THE WCA[ AGENCIES <br /> The state underground utoroge tank ident1f1cat1nn number is composed of the two digit county number, the three <br /> digit jur1sd1cl1on number, the six d1g1L facility number and the six digit tank number. The county and <br /> jurisd1ct1on numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The <br /> facility number must be the some as shown in form ^A^ The tank number may be assigned by the local agenCy, <br /> howyver, this number must be numerical and cannot contain an alphabet. If the ]Ocyl agency prefers the State <br /> Board to 6ssign the tink number, please 106ve 1t` blnnk ' ' ' - <br /> ` IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br /> , INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE ~LOCAL AGENCY USE ONLY' INFORMATION BOX <br /> AND FOR F0RWAJ`,1@INQ ONE FORM ~A~ AND ASSOCIATED FORM ~8^(s) TO THE FOLLOWING ADDRESS. <br /> \ <br /> �N������ <br /> ^ <br />