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Il I s[RUC HON S ()IL(C) PLL`I N IAC *B'
<br /> GENFIRAL IN I' t.S("I ONSn
<br /> L One FORM'8""shsall be completed for each tank for all NEW PERM.1717S,PERMH'CHANG119,,;RFMOVAIS and/or any
<br /> otherTANK INF 'I'IC)N(31ANCTF?
<br /> I This form should be completed by either the PERMrr APPLICAMpor the LOCAL GE Y NDERG O )°LANK
<br /> INSPFk'IX)R
<br /> . please tyke or`print clearly all requested information:
<br /> 4. Use a hard praint ori hu ng instrument,you are making 3_copies,
<br /> )Ir I A 'MARK ONLY ONE FI
<br /> 1. Mark a (X) in the box next to the inon that"best describes the reason the form is being completed,
<br /> 2. Indicate the D 3A or Facility name where the tank is installed.
<br /> I. TANK F—SC RIFr110N-(PC)MPI1Mi All,TITiEIS-H?UNKNOWN-,CI SPIX II
<br /> A� Indicate owners tank 11) #-If lis=Are is a tank number that is used by the ow-ner to identify the tank (ex,A1370789),
<br /> B. Indicate the name,of the company Haat manufactured the tank(cx..ACNIF'T'ANK MFG.).
<br /> C. Indicate"the year the tank was installcd (ex. 1987).
<br /> I). Indicate the tank capacity.in gallons(ex, 2S,W. )or 10,000 etc.),
<br /> H. TANK(X)MEMPS
<br /> r5 L If'MOTOR VFHICLFUE' ,check,lox I and complete iters B& C
<br /> 2.If not MOTOR VlqITCLE FUEL,quack the appropriate box in section and complete items B & D,
<br /> 13, Chock the appropriate box.
<br /> C, Check the type of?IC)"LOR VEHICLE,FUEL(if box 1 is checked in A).
<br /> D Print the chemical name of the hazardoes 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. 'IANK CONSTI2UC11ON..MARK ONYJ rrum ONLY 11`4 BOX A, 3,C&I)
<br /> 1.. Check only one item in'.I"ijpEOT SYST'IiK`ANK MAI' ILIAL, F.117RIOR LINING and CORROSION ROTE(7I"I0N.
<br /> 2. If OTHER,print in the space provided,
<br /> . PIPING IdySltM I)N
<br /> L Circle A if above ground;circle Uif underground; and circle both if`applicable.
<br /> 2. If UNKNOWN,circle;or if O`T`HER,print in space provided.
<br /> 3. Indicate the IsFaNK DETI C"I`ON system(s)used to comply-*ith the monitoring requirement for the piping.
<br /> V. TANK LMK DIElTrIlON
<br /> 3, Indicate the I.,ED: IC I EFEC,T"ION system(s) used to comply with the monitoring requirements for the tank.
<br /> VI. INFORMA110N ONTANK PIAT RN`[1,Y C'I S121)IN PLACI?
<br /> 1. E911MA ED i?rkTF IAST USED-MONIN I II f 4"FEAR(January, 1988 or(11/88).
<br /> 2. 0,SH tIATED QUANrrrY of IIAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> 3: WAS TANK FILLED WrI'FI INF R 11 MATERIAL?ERIA L?Check'Yes' or'NO'.
<br /> I P11 ' is SI""SIGN AND DNI`lI`ME FORM S )IC IT-0,
<br /> INS IJC"'I()N TX) "11H .k I, G CpI?s
<br /> 'I`he 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. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Boaz (916)7319-2421. 'Cha facility number must be the sank as shown in form "A. The
<br /> tank number maav be assitmed by She local agency; however,this number must be moncricatand cannot contain an alphabet, If
<br /> the local agency prefers,the State Board to:assign the tank number,please leave it blank:
<br /> ITISTHE ICI SPONSIBILYI' C)Ft LO(AL GI?N('Y ll"I T NSPF(Tl,S'I11E FAC 111ITTO VERHTY TII ?
<br /> ACCURACY Y OF 171E INTIORMA110N. 17113,LOCAL AGENCY IS IIESI'CINSIIII1 MR 110"C"OMP11-7110N OF 1141,
<br /> °IA')(:A..ACI.; 1SE,ONLY'INK) `IION I 1)I N )IC IX)RWARDING ONE FORM'A' ,SS CINI`I I�
<br /> Ma ' "s)T °IIIA Tk)11,0W1NG1ADDRFSS.
<br /> S FIVI l OF CALIFORNIA
<br /> grXrE IVI'ER R0SOURCHS C'ONI"ROL BOARD
<br /> C/o S. .F?I-I$.S.
<br /> ,Kr PRO(' ``NG ClIllyk
<br /> I.O.13OX 527
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