|
I .4'I'12IIC,1ltNP.:aIy COMPLU11NG -fr
<br /> GENERAL INS I RSJC HOf v
<br /> t One Ite1RM"II"'shall be completed for each tank for all NEW P 1`3,`PHRM`I'CHANGES, RPMOVAI.S ansa/or any
<br /> other T N INIa0WV—k'I"IC1N CIUNGE.
<br /> 2. This form ,h(-,aaJd lac con`!Istctcd by either the PE - Y17 PP ICAMI`or the LOGAL AGIzN(.,Y UN ERGR OND°P N
<br /> N P)UX-1 R
<br /> 3. Please type or print clearly all requested information,
<br /> 4. Use a hard I i?at r,=.? a7- n t, yoaa Marc mak ng 3 copies.
<br /> 'MARK ONLY ONE fi'Rd'
<br /> 1, nark a€ ?Xiphi the f ,x',asxt to the .tara<,that hest describes the reassn'the form is being completed. .
<br /> 2. Indlicatc, the DB,,4,o. , aC ihry namee v;he e the sank is in Ladled.
<br /> L TANK DESS S pT ON...,COMPTII,W,ALL 1'I`Ca: s"w IF UNKtsiOWN®So SPIX-
<br /> P. Indicate owners tart.11) of -If there is;a tank a°winbe;.r Haat is used by the owner to identify the tank(ex.B70789),
<br /> B, In"=ac,alc the nanic < 1hc, c ,mpanv that raanul,acter4°d the tank (vx. ACNII>TANK FG,).
<br /> Cl. Indicate the treat ,fic tat,_,was instalicd lex 1987),
<br /> lI", 11roficau,. the tare capacOv in i"Alk"'ns ( a.�5 , or '10,(M etc.).
<br /> H. TANK CO YNI-11
<br /> A. T li Hca 1 t R VEHICLE HICLa a k ail, check box 2 and complete irons B&C.
<br /> 2, )f n«t MOTOR VEHICLE ti`l..,i L,check telae appropriate bila in section r1 and complete items B& D.
<br /> BCheek the appropriate, box
<br /> (7. Ch-ca the ty,Pe of'?,ae r f O S 'sq,,t ll(T I: t C,T t (if box I is checked in A),
<br /> II. print the _b`,emi.. nanne the ten,4a mars su Bianca stored in the tank and the C,A,s, . (Chemical Abstract Service
<br /> ac=atrts= -),it box I is +O cheakcd in A,
<br /> ITI. TANK CON t'I2 C ON_.MARK NIS LITS ONLY IN BOX A, B,C
<br /> 1, Check only one iu,raa in TYPE, fltr SYS7'Ityl,"I`ANK MATERIAL,IAL, I`F tET2IO LINING and CORROSION I'1~rC)`I'I~C'I'It7N.
<br /> 2. If 01 1UR,print in the space pror idedL
<br /> M PIPING INTURMAT11ON
<br /> L Ciccle A if alcwr ground; circle 11 if underground,and circle both if rappiicat>lc.
<br /> 2. If 111'NKNOW`N c a, ,or if€)`(`III}Z print an space provided,
<br /> 3, lnslwatr the law I l,,'ITlf JUJON systersa(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK'LF.A IC DIT11p,,717OPI
<br /> i, 1,ac;ca=c the LUAK I>I.,£.;T°ILII v}sts°mrsj used to c° .aply with the Wades€tearing requirements for the tank.'
<br /> I. I?sal°`C1RMA11ON ONTANK t'I',lektlANENM C`I0SI-1I IN PLAC:.ii
<br /> 1. L�1I it I � T3e1l I~ I xi 1, l Ia yI 4I'II'MA (January, 1988 or 01/88).
<br /> 2. FS1,11MA 11`1)SSC AN't I i'a' of HAZARDOUSSUBSTANCE remaining in the tank(in Gallons).
<br /> 3, W,psi 1<,NK FILLED WITH Ilsi"RF 1<`t'rERIA ,y Check'Yes' or"`s0%
<br /> APPHcAmr muses'(SIGN ANDt _t1t'IT-111H FORM AS INDIC "I ST).
<br /> itsisrRumON FORUM'LOCAL NCII S
<br /> The state underground storage tank identification number is composed of the twat digit county number, the three digit jurisdiction
<br /> number, the six digit facility slumber and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained tai%calling the State Bard(916)739-2421. "I'he facility number must be the same as shown in Cornu"A". The
<br /> tank nurnbet Wray be assigned by the local agency,however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency cy prefers the State Board to assign the tank number,please leave it blank.
<br /> Yl'IS 77 €USPO NSIBIt 'I" oi-nm LOCAL AGENCY'111A71'IN`PITUM'171E FACILITY TO WIRIFY THE
<br /> . C"CURACIf OF171H,INIk,)R '11ON, '11111,LOCA N(Y IS RUSPONSIBLE, a'C>Z THE COMPL,EMO 'i`L a
<br /> 'LOCAL AGFNCY USF ONLY' NFO A'FION BOX AND FOR YURWARDING ONE"FORM W AND A,4.SC7M'11IP1
<br /> OR � �(s)°I'CI'I9III;Is011.0WING ADDREISS,
<br /> srsn,OF CLIi INL
<br /> 11ME 'B RESOURCES C3t(i MOT,BOARD
<br /> DNIA,1460 ING(.:I—ER
<br /> P.O.BOX 527
<br /> 1"11IIa1 TCyt7Np,CA W72
<br /> ® x
<br />
|