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<br /> GENERALI1 17ItU IFt:)NSa
<br /> One FOR "II"shall be completed for each tank for allNEW ER I'SP<RMr,17 C HANGFt. ," 13 OVAI 13 and/or any
<br /> other TANKK IMN)RMKIION CHANGE
<br /> 2. ,Phis foram should be completed by,either the PERM.rr APPLICANr or the LOCAL AGPNCY LT ER(; . I )'L'
<br /> INSPUA-70K
<br /> 3, Please type or print clearly all requested information,
<br /> 4: Use a hard poiztt bra°ititag iststruancrat,you are making 3 copies.
<br /> "LOP OF MRM.WARK OMA OW FL'Fika""
<br /> 1: ark an (X) in the box next to the item that best describes the reason the"form is being completed.
<br /> . Indicate the T) A or Facility manic where lite tank is installed.
<br /> . TANK DESCRIMON-COMPIMP,ALL L`I`IiIs S--Lta UNKNOWN-S'0SPE(IFY
<br /> A. Indicate owners laak ID#-If there is a tank number that is used by the owner to identify the tank(ex.AII70799):
<br /> I:1, Indicate the name of the company that manufactured the tank (ex.ACMETANK MFG,)..
<br /> C, indicate the year the tank :spas installed (ex. 1987).
<br /> I). Indicate the tank capacity in gallons(ex.L5000 or t0,000 etc.).
<br /> 11. TANK COMEND)
<br /> r1. 1. If I140`l' R VEJ11CLE FUEL,check box I and complete iteansI3&C.
<br /> d. If not MOTOR VEHICLE FUEI,check the appropriate box in section A and complete it:erns 13& Z1.
<br /> IL. Check the appropriate box,
<br /> C. Check the type of N1CY"I"1I; V171°1tC IX (UEL(if box 1 is checked in A).
<br /> I) Print the chemical name of the hacardous substance stored in thetankand the CAS,#, (C'henucal Abstract Service
<br /> number),if box 1 is NOT checked in A..
<br /> Iii. TANK CONSMC1 Tf C3 • .MARK ONE MIM ONLY IN BOX it,13,Ce&T)
<br /> I. Check oaaly bast:item in,rypIi CII'SYS-.r'1?M,",,'.NIC &'I'IaRIAI,, TN-TT-,CIO LIMN("s anis C;C?1tR IO I'I OI'I:('rIO .
<br /> 2 If OTHER,priest in the space provided.
<br /> IV. MING 1N1vORMXnON
<br /> 1, Circle A if above grow d;circle LI if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,,circle; or if 0,111EX,print in space provided,
<br /> . Indicate the LEAK DElYCHONsystcm(s)used to comply vith the monitoring;requirement for the piping,
<br /> V. TANK LEAK DITITWI-ION
<br /> 1, _ Indicate the L; A C7I TQC 1C) systc€n(s) used to comply wide the monitoring requirements for the tank.
<br /> VL. INta'C)IC FA°:TON ONTANK Pl,RMANFNrllY C IDSt:)IN PLAC:F3
<br /> 1.. ESTIMATED DATE LAST USED-MONI TI`IIj`YEA (January, 1988 or 01/88).
<br /> 1 ESTINMsSIED'01JAN'I`'ry of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS'IANK'IANFILLED W1`111 INERF MA TRIAL? Check'Yes'or`NO'.
<br /> APPI-I ° MU,4M SKIN AND DKIE` ITH WAM AS IMM(Wl'ita
<br /> m CJ€"ITON IaC)L'I1M LOCAL AGENC'10S
<br /> The state underground storage lank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number,the six digit facility number and the six digit tank number. The county and jurisdiction number,-,are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421, The facility number must be the same as shown in fosse "A". The
<br /> tank number may be assumed by the local agency;howevrer,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefer;the State Board to assign the tank number,please leave it blank.`
<br /> MIS THE ELSPO SHIUXI" OP`I IF!WCAL AGENCY T1lX1'lNSPFX..TTI"S'ILII3 F C;FIrCi' 'I`C) F; I `n III
<br /> ACCURACY C OF 111,"INFORMA110N. ITM LOCAL AGENCY IS RESPONSIBLE I '11113 COMPIEMON OF'I`TE
<br /> 'LOCAL a AG TSE ONLY"INK)RMAIION BOXAND MR FORWARDING ONE-FORM"A$AND ASS CINI`D
<br /> FORM W(s)-10 111F KNUMN6,ADDRESS.
<br /> I IM OF CAJIFORNIA
<br /> Ca/o . . F F?P.;so
<br /> I)A P a,'INKS CTMER
<br /> P.D.BOX S27
<br /> PARAMOUN17,CA 90723
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