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I "1RUC nO S 1A)TC COM PI lI C1FORM 1P
<br /> GENERAL 1NS1RU(-'110NS:
<br /> 1., One 17OR-I"T3"shall be completed for each tank for all NEW PERMrt'S,PERE r C I Citi S, EMOV I and/or any
<br /> other TANK INFORMA11ON(31ANGLI
<br /> 2, `3.'his form,should be completed by either the I"1:? PLIC" or the LOCAL AG13NCY UNDERGROUND 1" 1N
<br /> INSPEC7POP,
<br /> 1 Please type or print clearly all requested information;
<br /> 4. Use a hard point writing instrument,you are making 3 copies,
<br /> 10P OF PORN-WARK ONIM ONE
<br /> 1.. Mark an (7l)in the box next to the item that best describes the reason the Corns is being;completed.
<br /> 2. Indicate the,IkI car Taacility name where the tank is installed. + '
<br /> + p �, t 7 .a
<br /> I, 'IA DF.%7 r I'"I'IC) x. PI 1ri`CI T.I.MENS-ITz 11 C) - SPI °y
<br /> At Indicate owners tank It)#m If there is a tank number that is used by the owner to identify the tank(ex.A1370789).
<br /> 13, Indicate the name of the company that manufactured the tank(ex,ACMI',', MF(),),
<br /> C, Indicate the year the tank was installed(ex. 1987).
<br /> Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc,).
<br /> 11. 'rANK C()1N'T"I:WIS
<br /> A, 1,If t'd(YTCITC V17111ICLE FUEL,,check box 1 and complete items I1 sic C.
<br /> 2.If not MOTOR VEHICLE FUER.,check the appropriate box in section A and complete 'steres B& D.
<br /> TI, Check the appropriate:box.
<br /> C, Check the tyke of MOTOR VEHICLE FUEL(if box I is checked in A).
<br /> D. Print the chemical name of the hazardous substance shared in the tank and the C.C.S.#. (Chemical Abstract Service
<br /> number),if box 1 is NOTchecked in A.
<br /> III. 'rANK I SSR JC:fIO -MARK ONE'f111M ONLY IN BOX A,II,Cd&D
<br /> 1. Check only one item in'I'ts'PE OF SYSIMM,TANK MAIMRIAL,INTERIOR LINING and CORROSION PItCi'I"I!C°I't0N.
<br /> 2. If(.YFHER,print in the space provided.
<br /> IV. PIPING INMRMNnON
<br /> 1. Circle A if above ground;circle C if underground;and circle both if applicable,
<br /> 2. If UNKNOWN,circle, or if OTHER,print in space provided.
<br /> 3. Indicate the LEAK I>I;'I.I C7171 N systern(s)used to comply with the monitoring;requirement for the piping.
<br /> ". TANK LFAK 1)TI'TEX- O
<br /> 1, Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank.
<br /> VT. INIX)RMNnON O °C ERMA NIr.Ex 1,Y CIAMW IN lai c
<br /> 1. E,1ff,1MA`I1'U.) DA:IIE I.., ST USED« t N'TI'I/YEAR(January, 1488 or 01/89).
<br /> 2, ES°I'MATED CIA I*y of HAZARDOUS SUBSTANCE remaining;in the tank(in WIlons),
<br /> 3, WAS"T° FILLED WFFII INERT TERIAL? Check'Yes'or'NO',
<br /> APPLI(ANT CIT SIGN AND I)a l i WE 'INDICWTED.
<br /> 1 S-rP.VC. C) :11`1141 w L AGINCIPS
<br /> The state underground storage tank 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. 'Ilse county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Tigard(916)719-2421. T1le facility number must be the same as shown in form "A". The
<br /> tank number may be assigned by the local agency, however,this number mist 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 /> 1"I"IS II 3 R&SPONSIBI12PY CIF"111II WCAL AGENCYTITAT INSPIMN WE FA, , .IY 1 s 1"Y`1,11H
<br /> ACCURACY OF 11W,INFORMN171ON. 'I IE 1A)CAL AGENCY IS RESPONSIBLE FOR T II:?COMPU .I'TO N 011-111H
<br /> °I. L ACIT CY USE ONLY*I I I 'I`iON BOX.{INT)14OR FORWARDING ONE FOR "A"AND ASSOCIN110
<br /> FORM-Ir(s)TO 11111I FOLLOWING ADDRESS.
<br /> ST "I1A OFtCALIFORNIA
<br /> SrNM WATER RMSOURC Fit(1,BOARD
<br /> C/o S. . �._ , * .. a '-. , ., .. , ,a,.1'13
<br /> D,KrA PROCl HCl` F 1 I
<br /> �
<br /> I.O.BOX�p 527
<br /> q.W¢+ O CA WM
<br /> 0 ,
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