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<br /> UCHO NS FOR COMPTHFING I ) 'IF
<br /> 1"INVRAL IN'71RUCTIONS.
<br /> 1. One FORM"I3"shall be completed for each tank for all PFS N,PERMrI'CI1ANGFS, REOV and/or any
<br /> other'I`ANK INFORM/010N CHANGE.
<br /> 2This forth should be completed by either the PERMITAPPLICAN17 or the LOCAL G W UNDERGROIUM)TANK
<br /> Ii !>°PErMR
<br /> 3, Please type or print clearly all requested information.
<br /> 4. Use ahard point writing instrument,you are making 3 codes.
<br /> TOP OF C)RM."MARK ONLY C)NI,rl z"
<br /> 1, Mark an ( ) in the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA or'Facility name where the tank is installed,
<br /> . TANK DE-S RIPPIC) -") ru m Am.rriwS-IF UNKNOWN-SO SPErIFY
<br /> . Indicate owners tank 11 # -If there is a task number that is used by the owner to identify the tank(ex.Ai`70799),
<br /> B, Indicate tine name of the company that ananufactured the tank(ex.ACME"IAN MFG,).
<br /> C. Indicate the year the tank was installed(ex. 1987).
<br /> L). Indicate the tank capacity in gallons(ex. 25,( or 10,00 etc.).
<br /> H. TANK CONFiNI',3,
<br /> A� 1, MCKFO)tC) I[C 1 l'I
<br /> If VEHICLF
<br /> I ,,check box 1 and complete items 13& C,
<br /> If
<br /> 171-13L,check the appropriate box in section rt and complete items B& i).
<br /> 3. Check the appropriate be-<,
<br /> C. Check the type of tvlC)"IOR WHICLE,DUEL(if box I is checked in A).
<br /> I7. Print the chemical name of the hazardous,substance stored in thetank and the C,A,S, .(Chendcal Abstract Service
<br /> number),if box l is NOT checked in A.
<br /> III.; TANK CON,T11tUCpION- MARK 0I4 pI'I3M ONLY IN MX It,I3,C;&I3
<br /> 1.. (heck only one item m,rYpE CII SYSTE " /3iNK IMXI`LIRTAi„IIS I',RIC)I3 LINING and CORROSION IbROTEC 1710'x.
<br /> 2, If t)Z"HER,print in thespace provided.
<br /> PIPING INFRMA'110t
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> "? If UNKNOWN,N,circle,or if C)`I kIER,print in 'Space prov ded,
<br /> 3. Indicate the LEAK DF;'II;C.'C`IC.:N ate (s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAR DIT1`EGI`1ON
<br /> 1. Indicate the I;IAK IllI I?C"11ON system(s) used to comply with the monitoring requirements for the tank.
<br /> INIK)RMA11ON ONTANK PERMANEX11M CLOS13D IN PLACE
<br /> . F-511",IATL }i')A't'I?I., SI'USE[)-2i O II/Yi.,A (Januar}, 1988 or 01/88).
<br /> 2. ESTU° tk` F,l)CSL ANI'I`Y of ILA' hL)OUS SUBSTANCE remaining in the tank(in Gallons),
<br /> 3, WASTANK FILLED WITH TNER'I`ISI VI'ERIAL?Check'Yes'car'NO%
<br /> PI,I A i S""SIGN AND DX1'1VF1W,FORM ASIM)ICNIUD.
<br /> I S'FRIJ('6.TON FOR T11Ir I,C)C'.tIT.AGENCIES
<br /> The state underground storage tank identification number is composed of the ovo digit county number,the three digit jurisdiction
<br /> trumber,the six digit facility rmniber and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board(91.6)739-2421. 'Fhe facility number must be the same as shown in farm"A'. The
<br /> tank number may be assigned by the local agency,however,this number rust 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 /> D'IS"IE IC SPO SIBI XI`Y OF U1I3 LOC° F C:II.I '11)VERIFY'ILII?
<br /> ACCURACY OF 11111 Ih7I'ORMA IO . 11W,LOCAL AGENCY 1S RESPONSIBIX,t R`7111 C OMP1. :; (N OFTHE
<br /> 'L ,a'tGFN i)SE C),I I..W INFORMN11ON BOX AND FOR FORWARDING ONE',FSC) *V AND ASSOC INFED
<br /> IrC R "I"(s)TC) '11 i?FOLLOWING ADDRESS.
<br /> 9FIVIM OF C ,Ids) :'I
<br /> DA7 . c.P a-Iraq;CFNIMR
<br /> P.O.13OX 527
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