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<br /> INSfRUCIIONS FOR COMPIACY 1 *Ir
<br /> #W
<br /> GENERAL I llal'ICI,ICE[ONS:
<br /> 1. One FO "I3"shall be completed for each tank for all Nf.. P l ri ,P aR rr(, NGEN, REMO ;tAi'i and/or any
<br /> other TANK INIX)RMNIION CHANCIEC
<br /> 1 This form should be completed by either the PERMIT APHICANFor the 1.C)C .AGENCY UNDERGROUND UND T N
<br /> INS"j w
<br /> 3. Please type;or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are snaking 3 aspics,
<br /> P Oft 1 M:"MARK ONLY ONE : 10 i
<br /> 3.. hark an(X)in the box next to the item that best describes the season the form is being completed,
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> 1. TANK D1-' II"`HON P1,UI CAU.r1 °r S-IF UNKNOWN-SO SPFX3F,Yl-
<br /> A,
<br /> .
<br /> Indicate ownerstank Ill#-If thea is a tank number that is used by the owner to identify the tank(ex. Ai)70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons(ex.25,OW or 10,000 etc.).
<br /> 1. TANK CONIENIS
<br /> A. 1.If MOTOR VEHICLE FUEL,check box ! and complete items Ll &Cr.
<br /> 2. If not rrfC)TC)It V13111CLEFUEL,check the appropriate box in section Aland complete items II& I9,
<br /> YT. Check the appropriate:box.
<br /> C, Check the type of CSC?'rOR VEHICLE FUEL,(if box 1 is checked in A).
<br /> LD. :Print the chemical name of the hazardous substance stored in the tank and the C A.S. . (Chemical Abstract Service
<br /> number),if box'1 is NOT checked in A.
<br /> 111: TANK COMSTRUCHONKK MARK ONE ITM ONLY INBOX A,B,C:&1)
<br /> 1. Check only one item iri#'YPE OF S'Y5113 ,"I'ANK MKIMRI'AL,INTERIOR LINING and CORROSION PR(YI'EC TION,
<br /> 2. If U111E R,print in the space provided,
<br /> IV PIPING INFORMA110N
<br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle; or if C)1'HEM,print in space provided.
<br /> 3. Indicate the LEAK DEfE :'.l ON systecn(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LIMDUI'FX (3N
<br /> 1. Indicate the LEAK t)Cs"'I` C TION system(s)used to comply with the monitoring requirements for the tank.
<br /> VT.-INFO ZION ONTANK PE )SIS IN PIAS
<br /> I. T^ST7 ` TLIM DXIE IAS"T USED w MO I/YPA t(January, 1988 or 01/88).
<br /> 2. T::"IMATE QUANF''I"Y of HAZARDOUS US SUB,'I' NC remaining in the tank(in Callous).
<br /> 3, WAS AN "' TI..I,ED WITH INERT MATE' I,t L?Check'Yes'or'NO'.
<br /> APP11CANr MUSTSIGN AND DATE 111 13, I° .
<br /> ,TRUC CIN '13111 LOCAL ACE IPS
<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, The county and jurisdiction numbers 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 form "A". The
<br /> tank number may be assigned by the local agency„ however, this number must 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 /> Yr ISTHE IIII,S "IIIA. I'Y'CITE"1'11131 ,AGENCY'1 TAT INSPI� "1W,FA Idi'IT' VERIFY°11111
<br /> ACCURACY 011111H,INFORMN170N. THE CHINC-f IS RF-SPONSIBLE FOR 11€11 COMPLETION C)I TIH3
<br /> %LOCAL AGI C If USE CINI "INFORMAIION BOX AND limit FORWARDING ONE Int) *A!ANI) 1`I?J3
<br /> FORM-1r()I )111F FOLLOWING T) S.
<br /> sTNm It CALIFORNIA
<br /> 617Xt "I'IaR,#HS I.tR , CON ROL; )
<br /> fCT S,. nI'T.tPm .. ,. a
<br /> I"X ISR ,it NCi crwrm
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90M
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