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<br /> I SFRUC- CANS Ik)R C _ IZ1 NI E 'Ir
<br /> E wlgm.Itsismuc noms:
<br /> a
<br /> 'IaC u'l "£I'° shall be cora Pi-t-da for each 5., for all NEW PI n ,PF.R rF 0 ' 1ES, a OVAI S and/or any
<br /> 2. This form should be cccil al.'rcd by ether the PERM "C'APP11QW17 or the;LOCAL AGENCY UNDERGROITsIDTANK
<br /> 3. Please type or print clearly all requested information.
<br /> 4Use a hard point w-rhinf;instrument,you are nvaking 3 copies.
<br /> TOP OF FORM: "MARK ONLY ONE HTW'
<br /> 1- Telark an(X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2, Indicate the DBA or Facility name where the tank is installed,
<br /> I. TANK DF;SC'R1Vi1ON-C;C) I"[,.r Ili All,rI"r: S-IF UNKNOWN-SCJ SPEC TF
<br /> A. Indicate owners tank T1) # P If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> B. Indicate the name of tate company that manufactured the:tank(ex.AC: ll'I"ANK MFG.).
<br /> C. Indicate the year the tank wasinstalled (cx. '1987),
<br /> 1). Indicate the; tank catpaacky in gallons (ex.25,W)or 10,0)c(c.).
<br /> II. TANK C;'( 1`I' 1
<br /> A. I, If MO"1OR1,111(3,1! I lJE1,check boat and complete items FI C C.`,
<br /> 1 If not :��C:1"IOi l"MIFI'l(,`,LF;F`t.11a,F check the appropriate box in section A and complete items 1,3 D
<br /> Til. Check the appropriate box,
<br /> Chock
<br /> type of M(Il)'I(,)R V1111111011 FUL1 (if
<br /> D. Print the cbernic l mare f the hazardous ulltit ancepr,lorcd in the tank and the C".A.S,#. (Chemical Abstract Service
<br /> number), if box 1 is NOTchecked in A,
<br /> 1[ . TANK CON,91'R iC, 101d-MARK CINIa,TI1t ONLY IN BOX A,1I,C.&1)
<br /> L Check only one item in TYPE 01'SYS"I'T?'M,"1'ANK MAl"T'sTLIA'C„IxZ1' at(I0R LINING and CORROSION I'1YOTEC'ITO N.
<br /> 2. If Ci'I'HEI2,print in the space provided.
<br /> IV. PIPING INIa1)RM 'n0N
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> 2. If T7NK IC7`aaa',N,cttcic (it if O'HI R, print in space provided.
<br /> 3. Indicate the 1.FAK I BFI.'I'1.C"1'I()N system(s) used to comply with the monitoring mquirement for, the piping,
<br /> V. 1ANIC I,I F)1T17r,C7110N
<br /> . indicate the LEAK.DF1' 'I Cl'I0N systcm(c) cased to comply with the monitoring requirements for the tank.
<br /> V1. ININ)RM C`110N CIN"'T". NK F1M NT'IMII,Y (30SED IN PIA(II
<br /> L USII ri l l D DATI° I6 S't C S14)-`�IONI'll FA (January, 1988 or 01/88).2, I S`FTM 4l VD C)Ch.hI*1'I"1 y'of I lrl Z!y.TI134 TJS S Cly,l"AN(T'1 rc,mattting in the. tank (in Gallons).
<br /> 3, WAS"ANK FILLI'D WITH INF'IKI'14JA`1lr,RlAL? Check 'Yes" or'i'0',
<br /> APP1JCANI'JMtJSW SIGN AND O IV`!1I)?FORM INDI(Wild),
<br /> 1N,q'R1Y( I C N IaC.JII'1"111; O(AL CII NC.IWS
<br /> "Che state underground storage tank identification munber is cumposed 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 numbqrs are predetermined and
<br /> can be obtained by calling the State !,'bard (916)'739-242L The facility number must be the same as shown in form 'A". The
<br /> tank number may be ,"signed by the local aagcnc,y; 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 /> TI'Ts lim RuspoNs113I.nT 1$'1111i 1,0CAT, Ci1 W—f°11l/V1'1NSP1:—1 '17JE;F?A(IIAI'1T"1'0 WiRTTF"Y'11113
<br /> ACCURACY_ OF 11111 INIX)RMNIION. 7111'LOCAL ACU24CY IS 121::5" ONSTBIE I 312 1111:.COMP111110N OP 171E
<br /> *LOCAL AGENUY USE ONLY*1N1UlRmNn0N BOX AND Ik)R.ItORWARDING ONE Ik)RMASA D A 5( "IA11::0
<br /> I ) -Jr(s)TO`1111,F 111 I GI°IT RE&S.
<br /> grNIT OF CATIMRNIA
<br /> SF 11T,` +"XI'FR .ILS BICC C.`f➢ATI RO 117
<br /> C/o .W.I=1 Y.'s,
<br /> DXfA PRO(;I- SIN(. c[W1 l ;
<br /> P.O1X)X 527
<br /> P. . OUNI CA 90723
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