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IN�N'RU(NIONS FOR COMP1,17,17ING FORM'fl'
<br /> C`IIEISI [toils ISI:EII
<br /> L One 3 i.IZM 1I 1h a" bet�onn,,nlcwd for each t:aaa r, for all NST"PERNM'S.,PrqtMrI.`(1IANGFS, R ?. OWAUS and/or any
<br /> other e.'° IFC Ia F )RS41VI"1C:)IS CHANGE,
<br /> 2. This fo 4n should be conipteled by r nh.vr the tib I' C'C" ; "r or the LOC" >AGENCY UNDE,RGROUND TANK
<br /> INSpi CT �
<br /> ,s.� Please ,pe or p6 nt cicarlt all requested)information,
<br /> 4. E sc a n.u,d paint Arifi g mstra meat,you arca to°mki g 3 copies,
<br /> TOP OF FORM; 'MARK ONLY ONE 17M'
<br /> L Mark an, (X)in the box ,next to the,team trial best describes the reason the fora is being completed,
<br /> . Indicate the S9(? or € ,cility carne �,vttere the tank is installed,
<br /> L TANK I) ESC R P12C)il®C: MPLIN7i All,E -EMS-lir UNKNOWNSo SPFX31rY
<br /> A. Indic<at;a irwners tan's.I L -If there is a flank number that is used by the owner it)identify the tank(ex.A1370789).
<br /> 13, Indicate the na€ e of the company that manufactured the tank(ex. ACME?TANK MFG.'),
<br /> C". Indicate the year the tank was installed (ex.1957)
<br /> I). Indica€e the tank capacity in galions(ex.25,001)or 10,000 era:,),
<br /> 11. 'TANK C.OS I`IiMIs
<br /> A. 1. If MOTOR V IIfc t,1;f,1Ta.9 ch Ha.k box I and complete ite.rre B& C,
<br /> 1 If rant MOTOR VF111CLE,t t_1: , check »,a alsproprr:Ate box in section A and complete items B& D,
<br /> I3. Check the appropriate box.
<br /> C. Check the type of I01'OR V1,111C LE,l IJE L(;f box 1 is checked in 1C);
<br /> I). Print the chemical name of the b azardous substance suared in the tank and the C..A,S, . (Chemical Abstract Service
<br /> number) if box t is;fitYT chcckcd in A
<br /> 7IL TANK CO UC71 ON-MARK ONEGIlM ONLY INBOX,fie,,I3,C&F3
<br /> 1, Check tenv one item in"t YPE 0 sy`S I FM,"a'ANK s>y'['I`slCJAL, INTERIOR TYIOR LINING and CORROSION I't20T1I ,,,("I`ION,
<br /> 2, If OTIIER,print in thespace provided.
<br /> IV. PIPING INIX)Et ti°1ECI1
<br /> I. Circle A if above ground;circum CI if underground:andcircle birth if applicable.
<br /> 2. If'C UNKNOWN,circle: or if OTHER,paint it space provided.
<br /> 3. Indica,<„ the LEAK 1)1,131`C-31011,!sysfeln(s) used t i,cram,,N with the monitoring requirement for the piping
<br /> V. 17ANK LFAK DINTC-110N
<br /> 1. Indicate the Ia iC:DETFC110N systen,(s) used to comply wham the mcaaitoring requirements for the tank,
<br /> VL INFORMNITON ON TANK 'E RMANEM L,' CLOSET)I)Ind P_ C['
<br /> 1. From ail h3 I)tt,rp,"uks-F fSEf)-)Ctl;x''`s'i,I i..".A f(January, 1988 or 01/88).
<br /> 2, I"SI „MJVI'7:t QCaANTITI-Y of HAZARDOUS US SLTE's4`I`ANC'E' remaining i .the tank(in Gallons),
<br /> 3, Lk S'I'ttNK E'ILLT..",I) W1111 INERT MA'IVRIA.,? Check 'Yes'or'NO'.
<br /> APP11CANI'MUS17 SIGN AND ) :1" ' E I S'C)RM AS INDICWIT0,
<br /> i S.[kBUCAI N 17OR11II OC AL z C3ENC E m"E
<br /> ']"he 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 [lie six digit tank number, `fie county and jurisdiction numbers are predetermined and
<br /> can be obtained by catling the State Board(916)739--2421. The facility number must be the same as shown in fawn "A". `:fhe
<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 agenc=y prefers the Slate Es card c)ass gn, the rank number,please leave It blank,
<br /> IT IS'I7.I1 R SE"C) SIEIEI,111 C)Ia'I`Efit LOCI.AL AGfh`sl `" 'I" E`IN,%P L"I 17111 FACIl,i'°Y'170 VITRIF 'C'I ?
<br /> (X'U: :CC)Ir'I'E IE 1 FrC)Et._ J`1ON. '111EE IDC AL AG EFIC'Y IS RESPONSIBLE"MR 1111:COMPLErnON OF 1111I
<br /> *LOCAL G C" 7SE ONLY*I I ")RM/VE'I()N 13OX AND 17OR FORWARDING ONE FORM'A' 7 A&S"GINITT
<br /> FORM 1-0 11TE FOLLOWING ADDRILSA,
<br /> S"i E OF Cd 11F) GI
<br /> 91'All! iVflE ISG CI',S(70.NrR0L BOARD
<br /> Cff3 S.W.I7clp.S.
<br /> IyC c 13OX 5:27
<br /> r _MGka J, CA Ar72_3
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