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<br /> T I`RU(.I1OS FOR")WPIHFINGi 1 <M�'B"
<br /> GENERAL NIi172CI(:110NS.
<br /> 1., One I`'C)RM "I3"shad be completed for each tank for all NEW 1SERMY°S,PF,RMfI' IANGF' , Iti:"Fx1OVAI.1S and/or an
<br /> other TANK 1NTk)R 'I'ION C'ITANG13
<br /> 2. This form should be completed by either the PERWl'APPL;IC or the LOCAL AGE.NCg"Y LINDELLGRi), NO TANK
<br /> 3. Please type or print clearly all requested information,
<br /> 4, Use a hard point writing instrument,you are making 3 copies;
<br /> TOP OF R)RM: "MARK ONLY ONE rnim"
<br /> 1 Lark an,(X) m the box next to the item that bast€lcscribes the reason the farm is being cornplated.
<br /> 2. Indicate the DBA or Facility nae=whcrc the onk is tstd llec.
<br /> 1. TANK D SC RIY17ON- ;C) 'IXUT1 AI,J,LI7:? S-.IT''I NKN(WN-SC)1SI'I' :I1
<br /> A, Indicate mviv,;rs tank 11) # - If there is a tank number that is used by the owner to identify the tank{ex.A13707 Q),
<br /> 13. Indicate the name of the company that manufactured the tank(ex, CME" LAN F G.)-
<br /> C. Indicate the year the tarok was itn>talled (ex. 1987),
<br /> I). Indicate the lank capacity in gallons(ex.25,000 or1J,tlth'i etc,),
<br /> 11. TANK WNIENI'%
<br /> A. 1.If M(.)`I'OR VEHICLE,L'C'1I?L,,check.box I and complete items B & (':
<br /> 2, if not ?4IC)"1'OR VEHICLE FUEL,check the appropriate box in section A and complete items I3 R 17.
<br /> 13. Chock the appropriate box.
<br /> C;. Check the type of Xff) OR VEHICLE, EL(if box 1 is checked in A).
<br /> L). Print the chemical name of the hazardous substance steered in the tana and the C,A.S. . (Chemical abstract Service,
<br /> number), if box 1 is NOT checked in A.
<br /> M. TANK ...NSS"1 RIUC HON-MARK ON ,,17177M ONLY IN I3C) , 1,(g&I)
<br /> 1, Chock only one item inTYPE OF fS'Y5fFy1. .A%NK M,,%1FIRIAL, INFERIOR L,INNING and CC)RiZC)SY-3N I'ZLC3"1LF(,I ION,
<br /> 2, If O" IlL,s , print in the space provided.
<br /> IV. PIPING 1NP()RMXIION
<br /> 1. Circle A if above ground; circle I.7 if undergrourrdl and circle both if applicable.
<br /> 1 If UNKNOWN,circle; or if OTHER,print in space provided,
<br /> 3. Indicate the TEAK DI'.'ITC:'110N system(s)used to comply with ilia monitorma requirement for the piping,
<br /> V. '1 ANK I, I( I FUEC 11C)N
<br /> I. Indicate the LEAK DE,71IsC'1ON systern(s) used to comply uxfth the monitoring requirements for the t:axlk.
<br /> VL INFORMA110N ON Tfink{PEIRMANi '1 L CLOSE—I)IN PLACE
<br /> I. FS"TIM 1"I I) I3/01 LASS' AR USED-M(Y 7UJ/ F (January, Igtig"or 01/88),2. I: CI:4ffy`lUD C1L?ANI`dTY of IJAZA ZDOUS S B'34'1NC rern wining lir the tank-(art Gallons),
<br /> 3. WASTANK i II,,I?I,) riji INI:.1'C`I`y4A'IT',.RIA[,f Check Y&or�INYO'.
<br /> APPL C NI` IT L'RICIN AND I)A"I7 311B R)RM AS IN17I( 1135).
<br /> IN;sNRUC170N I'C)R°17IE LOCAJ.,.,A(;I,lN(jTr_1;
<br /> The state under-round storage tank identification number is composed of the two digit:county number, the three digit jurisdiction
<br /> number, the six digit facility number and ilia
<br /> six digin tar � ictiora numbers are predr 10crinined and
<br /> '� a�rausari>t;r. 'I`hc county rzrad jwarrsd
<br /> can be obtained by calling the State Beer(! (11Ci)733 241, The facility number must be the:same as shown in form JY. `floc
<br /> tank number may be assigned by the local agency: however, this mrinbec must be numerical and cannot coma ii an alphabet, If
<br /> the local agency prefers the State Board to assign the tank number,please"leave it blank.
<br /> I'1° S 111111211~SI'C)MSI1311,l`I° CSI="11111 1A)CAJ.eIGENCY'1°11 '1`I SL'1,XXS 1'1113 FACII.XITTO V11L211-f'11111
<br /> ACCURACY OFTHE� INFO 1°OM THE Y_OC AL. G1�1Zgt IS 2T NPONS LE.FOR°17LL�1 CO I'1, L7C)N 011THE
<br /> C. 1,
<br /> "LOAGENCY USE ONLY*INFORMA7170N BOX AND Ik)12 )RWARDING ONI1,1'()12 'A' ANIS ASSOCINIIx,1)
<br /> gar 7�:
<br /> A t
<br /> P,0,,110X 527
<br /> PARAMOUNT'CA,%7_735
<br /> 4
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