|
INSTRUC11ONS POR COMPLIRING FsDRM'IV
<br /> 1, Cant, FOR\!"B"shafllle,Completed for each tank for all NEW PERmms, 't.'. I'auNcius, Ri-,MOVAI-S and/orany
<br /> o kpiK INMIRWdiVOON(:11AN(;17,-
<br /> 2,
<br /> c 'Y INN RO This fo m nhould be rolnpleled ev cither the PffRmrI'APPLI(:ANFor the L0(:AL AGENC DERGA UND1`ANK
<br /> 1 please or print clearly all requemed information.
<br /> 4, Use a hard point wofinl,'y insiculnent.;QCs u arenlaking 3 cofnM
<br /> 'POP OF PY,)RM- 'MAIRK ONLY ONE,I'l-EM'
<br /> L SJ ark (X) ill tile box neyt, to the item that best descrihes the reason the form is being,completcd.
<br /> Indicate the DBA or Fjrflav nanle where the tank is installed,
<br /> I- "I"Ar"M AIJ,OPNVS-IF UNKNOWN-SO SPEX-IIN
<br /> A 4,>wncm 1,ant,!,I-) k - If here is a tanknundler that is used by the owner to identify the tank (ex.AB'70789)
<br /> it, lndicak, ,he nonc,c),"the cor,"pmly that manufactured the lank(ex.ACME TANK MhG.),
<br /> indk'alc tae the €-wk wav� �w�,uaHed (ex, 19187),
<br /> 'ndicaac thC colk c"R Padly anyallons (ex,25,000 or 10J)N)ctc,)-
<br /> 11, TANK(X)N`1'F,N`11,1,s,,
<br /> 1, If 1 RD'R Vf"11 HCi'IF RJH,cilcck box I red complete items B& C,
<br /> If nn M0,R)R VF]IM"01" PUFL,drcck theappropoate box in section A and complere iterns 11&11
<br /> Chcck thc, approprialc box,
<br /> C, -71heck the lyf-,c of NIOTOR EI HCLE FUEL(if box I is checked in A).
<br /> he cheuuca! rwmv"'ofthe bn-,,,ardous substance stored in the tank and the (,.A,S,#. (Cliernical Abstract Scr6ce
<br /> rum be,,r), if hoe I is !,,'0'Vchcckcd el A,
<br /> 19, 'JANTK MARK ONE RT,M ON115'IN 11k)X A,B,C&D
<br /> 1, Check only ons hem, IN,11"REOR HNING and CORROSION PROTE-C7110N.
<br /> 1 If 0-fl,IFAprint in the space p�ovided,
<br /> 1,V, 111PING 1NFORr,,9A'110N
<br /> L Circic, Ail"ne""Ve zround� circle (I ifutedcr?,round: and circlebath if applicable,
<br /> dc� or 6",01-11,11 Print in so cc Prvided,o
<br /> 1 If UNKNOWN.6 -a
<br /> 3.
<br /> Indicate the 1,1"AX, 1)1`11�(71'10N systcnl(s)used to comply with the monitoring requirement f©r the paung
<br /> V, TAW, TXAK 111311,3J 71100
<br /> 1, Indica',o the LFAK D191"CRON sy'llem(s) axed to comply with the monitoring requirements for the tank.
<br /> VL i[N1rORMJVFION ON TANK PERMANVIN11M CLOSF,D IN PL CM
<br /> 3, FS-E1NM-A',FFD DATF [A-ST 13S,1`115-FICIN rl[/Y[,-,',R(January, 1988 or 01/89),
<br /> 2, ESTVA,N1171)07,'A."11TY of HAZARDOUS SUBSTANCE' remaining in the tank(in Gallons),
<br /> 3, ASTANK 11111,J) W1111 INT IRXMATCRJAL'' Check 'Yes'or'NO',
<br /> APPI JC'A?�r MUS3-1-SIGN AN]-)D)VI-E THE 170ILM AS INDICNI 1411
<br /> INSTRINTITON FOR1111?LOCAL AGfEN(IHS
<br /> 'Dic state tank k1crnific'Rion number is composed of the two digit county number.the three digit jurisdiction
<br /> rtn"O'ber, the six di-it fac0hy number wad the six digh tank umber. 'llie county and jurisdiction numbers are predetermined and
<br /> - b uuned by c?lling the State Board (916)"W-2421, E�he facilit number must be the same as shown in form 'A". The
<br /> can I e ob y
<br /> trink number may be assigned by the katal`agency; however, this number must be numerical and cannot contain an alphabet. If
<br /> the loral agency prefer-, the State Board to assign the tank number,please leave it blank,
<br /> rr IS111E,RV-SPORSIBITY111 OF 1`11F 11)0M,AGEN(7Y111AT INSIII?CrS 7111i FACH11'Y'll)VERIFY111E
<br /> -TObf, '1111,"LOCAL AGEN('Y IS RF-SPONSIBLE 1UR`11IE COMPLEITON OF 7711114
<br /> ACC ItAlf'y OF'OTE 1NIzOIRM/10
<br /> 'IDCAL A(3IfN(,TY`USE ONLY*INFORMP01ONBOX stND 17OR FORWARDING ONE FORM*A"AND AW)CINI'liff)
<br /> -11s) -)LLO
<br /> FORM'Jrl 'I'O'HIR Ft WIN(i ADDRI I�%&
<br /> STA17F OF CAJAR)RNIA
<br /> SIS U', WN!'ER, RPSOURCES CONWROL BA)ARD
<br /> DeVIA PROC1MING CP's(FER
<br /> P.O.BOX 577
<br /> PARAf,40131q)"CA IXY72-3
<br />
|