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<br /> fblSFRUMTONS FOR CX)MPLITIING FORM"Ir
<br /> GENERAL INS71'RUC"IICI Sa
<br /> I, One MRM T"shall be completed for each tank for all NEW PERM I , FRMrI' °IIAN(; S, REM0 gni N,,a,nd (
<br /> other TANK NITC)RR A"1ON CITANG
<br /> 2. 'Hisform
<br /> f rm,shoidd be.completed by either the :R rI`APPI C:A 'I'or the LOCAL AGEM.Y C3 TIIERGRa,)L)ND TSA K
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a herd point writing Instrulxs=4 you are.aaaaking 3 rop;cs.
<br /> TOP OF FORM."SARK ONLY ONE rnrMw.
<br /> 1. Mark an (X),in the box next to the item that best describes the mason the form is being comple tee.,,
<br /> 2, lndic�te the I k A 6� i facility name where the tank is installed.
<br /> 1. .I"AN DP-S(,R I'TO :»C.CTA I"T,Icni Ai t,riiI -IF IJ KNOWt4- )SE"I?(;ITrY
<br /> A. Indicate owners tank II)# e If there is a tank number that is used by the owner to identify the tank (ex,A1370799).
<br /> B. Indicate the name of the company that manufactured the tank(ex.AC MM3 TANK 1'(;i,
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> I). Indicate the tank capacity in gallons(ex.25, or 10,000 etc.),
<br /> 11. `TANK MMITIMS
<br /> A. 3. If.M(Yl'(.)R VEHICLE FUEL,check.box 1 and complete items€3&C.
<br /> 2, if not N-10L OR VE"HICLh,FUEL,check the appropriate box in section A and complete items I2& 1'a.
<br /> B. Check the appropriate box,
<br /> C. Check the type of MOTOR VEHICLE;FUE'l.,(if boy. 1 is checked in All,
<br /> I). Print the chemical name of the hazardous rubstaance stored in the tank-and the C;,A,S. . (Chemical Abstract Sin-vice
<br /> number),if box I is `gar checked in A.
<br /> III. TANK CONS-FR TC"ITCH -MARK CIMi rmm ONLY IN I3t7 A,B,C.&T
<br /> L Check only one item inTYPE OI^S'Yf,I1TM,TANK MNI`}IRIAL, INTERIOR LENING and C'€')I2ROSTC)NPIZO'1'1:?,(']'I()N.
<br /> 2. If 0'111EP,,print in the space; provided,
<br /> IV. PIPING INFORMIMON
<br /> 7, Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> 2 If UNKNOWN,circle.; or if;OTHER,print in space provided.
<br /> 3. Indicate the LEAK t)ti'T-.(-I'10N system(s) used to comply,with the monitoring requi,rernew for the piping.
<br /> V. TANK 11 1)I:I['I:IM ICBM
<br /> 1. Indicate the LEAK E` 1,'(']'I(')N systesn(s) used to comply with the monitoring requirements for the tall k.
<br /> VI. I:P4FORMA'I ON ON TANK PERMANEWFLY CLOSM)IN PLACES
<br /> L FSI'IMA'171[) DA'I"I;I.AS'r USI I3«MONrlll/Y'I?;AR(,J anuaary, 1988 or(t'I./88).
<br /> 2. ESPIMAI'ED QUAT7I'I'I"Y of FIA7AITT;OUS SUBS:I'A NC"13 remaining in the tank (in Gallons). ,�
<br /> 3. WAS TANK FII 3,ED Vt'riii !NFIRT MATERIAL? Check'Yes'or'NO',
<br /> AI P11' r U M'aIGN AND I)A`n °I II';Fx)Rm AS I I7I(WI I?I7,
<br /> INS-17RUC'I'IC)N 1701 7TIE LOCM,AGE C:IHS
<br /> The state underground storage tank identification number is composed of the two digit county nusttber, the three digit jurisdiction
<br /> number, the six digit facility number and the sax logit tank number. The county and jurist€fictio) numbers are pre eternihied and
<br /> can be obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in,fomes ",A"_ '111e
<br /> tank number may be assigned by the 'local agency: however, this number must be nutnerical and cannot contain an alphabet, If
<br /> the local agency prefers the State Board to assign the tank mtrnber, plcase leave it Nick.
<br /> ri"IS`ILII?R13?SPONSIBII..TI"Y OP-ME WC'AI,ALAI.;NC Y"I"TTA I' TO VT^.III1,T`11TE
<br /> ACCURACY C Y OF 1111:(INFO M TO . 'ITIF f CAL lC A-I C Y IS R 'SPONSII3Lfi FOR 171 (70MPLI1"I O 01 `I` E
<br /> "I. AL AGENCY USE ONLY"INFORMN110N BOX AND 17OR IaCM ARDING ONI:?MRM 'A"AND A11,31SOC:'INI q)
<br /> IAC) -B-(s)TO O 'I E F01 I..0 I G ADDRESS.
<br /> I'A'I' CTI?C".AI, FOR IA
<br /> 11101W1,13 MER ECI MOW-MS S CON-1 R,C)I,RIM RT)
<br /> 5.,'`I I f'kGf.`TS3SlW3 F,f.`' ,.,.
<br /> P.OIK)X 527
<br /> PA MOUNI`,CA 0'72:"3
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