|
Aw—
<br /> INSTRIX711ONS FOR C O PLInT N 1= PM 'I3"
<br /> 31'NisIF.INSI1Zl t q g( gyy p# g y y $g gayp $gg
<br /> I. One$4 r'I'-,',M FA""'hall be c�.3:P l.ed :...,.. r;ach Link i.$�'r all NEWPla AIN, S F &P&..k' l..#0..:£, E`4.8'.14"5.(`Yx`AI ;R and/or anv
<br /> . This forst should be c omp;artc t by either the PF I`:p APP11CANIr or the LOCAL AGENCY UNDERG LOOM "T'AN
<br /> INSPt "I'OR.
<br /> ... 3. Please a t or print dcady;all requeso,'.f infornnalion.
<br /> 4, Usc a Ivan] p ttnt wrifivg ins an-,,<nt,ync)u are making:3�cope;s.
<br /> 1, Mark an (XI in tFte:box next to the ikeni that best describes the reason the farm is"being completed,
<br /> 2. Indicatc the DBA,or Facility name wb rc the tank is irsstatled,
<br /> I, TANK DESCRIPPIl:'II -C MPl Ifff,All, "i'ISY[S--Ill UNKNOWN-S0 SPECIFY
<br /> A, Indica'=.c:owners tan 11 # -3f there is a hank r umber that used by the owner to identify the tare(ex.AB70789),
<br /> I3, ladica?c the nwite:of the cornpaany that manufactured the tank(ex.ACME,r N MFG.).
<br /> C;. Indicate the year the tank was installed (ex.1987).
<br /> , Indrd,at,e the tank capacity in gallons(ex.25,00£1 or 10.E etc,).
<br /> 11. TANK C CJNI'I N'f S
<br /> A, 1, If MOTOR V ITIC IA FU11,11,check box I and complete items B& Cr.
<br /> 1 If v t %A()1°f ttk VEHICLE F I,I=_,r ch ck the appropriate lien:in section A and complete items 13& D,
<br /> , Check the appropriate box.
<br /> C: Check the type of IMOTOR V1,J HCIT FUEL(ii box 1 is checked in A).
<br /> 13. Print the chemical name of the hazardous substance stored in the tank and the (,.A,S, . (Chemical.Abstract Service
<br /> number), if box l is 'NOT c peeked in A,
<br /> I_ TANK(i NS CU(717 1N ARK,ONE OEM ONLY IN I ,B,C"&D
<br /> 1, Check only tine it nr in`Fy'I E OF SYS .stn TANK MAI.II:i,I3LAL,INTERIOR LINING carni CORROSION I' C)T C`I ICIN.
<br /> 2, If"?"["tIER,print in llw space proSv,ded.
<br /> '. PIPING; )WMjVI'I N
<br /> 1. Circle A if above ground; circle TI if undergrc3tandi and circle both if applicable.
<br /> 2. If t:NKslOWNg^,circle; or if OTHER, print in space provided,
<br /> 3. Indicate the x.&.sA F31. `TIC"1 tr3N system(s) used to comply with the monitoring requirement for the,piping,
<br /> V. TANK 1XAK DITIV(7170N
<br /> 1. Indicate the THEA DE'A'EC"I'ON s=kste n(s) used to ccrmplu with the monitoring requirements for the tank,
<br /> 1. INFORMN17ION ON'1`AN I'l.,,RMANIINIFIX CLOSED IN PLACE
<br /> C:
<br /> 1. FEI'VADAUED t?AI i LAST US D-MONT11Ia"`s L'AR(Jan nary, 1988 or 01/88),
<br /> 2, IFSS 1MA" Vit) C2LtANdTFY of I IAZAPDOUSUBSI:,�NC E, rema ining in the tartly(in Gallons),
<br /> 3. WASTANK FTIJYD WITH I;ERT A"I ERIAT:a Check '�cs'or'NO',
<br /> APPLICANT NT IJ P SIGN AN 3t4'I'I1"1111?IFORM AS INDIC,Allil).
<br /> IN 'I11J(711(C3N FOR`1 1?FffL GEN( ES
<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 tiro six digit tank number. `[he county and jurisdiction nu€tbers are predetermined and
<br /> call be obtained by Dining the.State Baird (916)739-242L The facility number trust be the same as shown in farm"A'. The
<br /> tank number ntay be assigned by the lcacal agcnry, however,this number must be numerical and cannot contain an alphabet, If
<br /> the local agency prefers the Stan, board to gn the tank at=umbcr,please leave it blank.
<br /> 11'IS idllx IClrSPONSIBII.1'1°1' (11='UIE I,CI(IA;, GENC"*f"�"'111A `I SPPX7'S 111E F C I[inl °' CRU 1111
<br /> AC('URACY OF11111 INFORMA110N, "IME LOCAL AGENCY SESPONS 11s'FOR111H C O PLUITON OF11417
<br /> 1110CAL€Gl<NN e LIST'ONLY*INI "IRINAXPI(IN IXXX.AND POR 1ADRWA DING ON14 FORM A 'ANIS S (-3sV11lD
<br /> IX)RM-W(s)TO F O IX) CNG ADDRUss,
<br /> SI Ills`01,( IAIFrUt(NI
<br /> SF `l §"Fdilf RENOURCIIN(70NWROLI IZF3
<br /> C/O S_s3'.1.FLRS.
<br /> 13IVE/k F'I£ kSING L;'l.lTI R
<br /> PO,BOX 527
<br /> PARAMOF.tl `Xr7n
<br /> a
<br />
|