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<br /> IN5I'RU(n 10N'S FOR(X) PC,J 1 C)SSC) 'IV
<br /> GENERAL EN[FURIA,711ONSk,
<br /> Tshalbe completed for tank � E* ' ,PEMI1CAGU , OAaa€/tr 1a
<br /> er I,. t IO1CMA°I1�() CHANGE.
<br /> 2, Fhi% .t,.a,;,should tee €gra pl fed by either the IT'R t I`AJyPL1C`.AN1`sir the LOCAL AGENCY UNDE ",'GRO lND TA
<br /> 111case.vpe or print`,tf arttr all requested information,
<br /> ', Mark-„r (X)iaa the loos next to the itern that best describes tire reason, the form is being coni letcel,
<br /> r., Indicate,the DBA,o,r Facility nanne where the tank is installed,
<br /> 1. TANK CwOMPLIB"17i Au;I''1: 5-117 UNKNOWN S()PYWII
<br /> Ay Indicat.,owners thank: II) If there is a tank number that is used by the owner to identify the tank(cx,A B70759).
<br /> R yndicatc the rrame of the company that manufactured rhe tank(ex.AC°MII°s'[ANK MFG.).
<br /> C lnde care the year tine Tank was installed (ex, 1957)..
<br /> 1), I dficwc the tank c p€chy in gallons(ex.25,E of 10,Effk)etc.).
<br /> I. TAN C;C) IENI'S
<br /> A, I, I, �OTOR VEHICLE�UEL,check box I and corsplele items IB&C;.
<br /> If not IvIC)'1"C3R`T EI 11CLE l 171sT„check the altpro rime box in section A and complete items B&T3.r,
<br /> 13, Check the approprhaw bo,,,�.
<br /> C, Check the ryla of M01 t k I FECLf I C I:.I,t f box I is checked in A).
<br /> F X Print the claa,mi al nam e i'the hazardous substance;stored in the tank and the C.A.S, . (Chemical Abstract Service
<br /> n aazl, ); i('tasx 1. is `(Yr :9aeraked in A.
<br /> IIT. TANK C"C)t"va ;11C:I ON-MARK ON11-i rIEM ONLY IN BOX A,13,C:&I)
<br /> L Check only one item in"l YPE OF SYS I FM,TANK IVIA'T`I:`IUAL, dNIT'lIUOR LINING and CORROSION 1'I OTECI ION,
<br /> 2, If£)'I'II'Y R,print in the space provided,
<br /> IV. PIPING INIT)WIANI10N
<br /> a, Circle A if above l;roc3ad;circle U if unc ergtoundS and circle both if applicable,
<br /> 7, If UTNKNOWN,circle. or if ta` HE'TL prin't ira space: Iarovidcd.
<br /> 3. Indicate the TA i f)F`I1>CTFI0N systy rn(s) used o)caorupiy with the monitoring requirement nt for the piping,
<br /> °T.AN IPAIC:I)ICIl d1'IC)
<br /> 1. Indiccam the LFATC DET FC1 FION systern(s) used to comply with the monitoring requirements for the tank.
<br /> VL 1NFORMNIION ONTANK PER A E ILY(3,0SED IN P1 AC
<br /> I. L',51 TINLAT D I)ATE�' I.AS'1'USI'1)-MC)WII/YEAR Nanuary, 1958 or 01/88).
<br /> 0U,/`tx,,rrrY of ITAZ,A I)t US SUB5TANC`E remaining in the tank(ira Gallons).
<br /> I WAS'JANK III 1,1:1)WITH INEIRTML°I'ERIr'L?C:'heck'Yes'or'NO',
<br /> AFTLMCA T'MUSr SIGN AND )A`I a'1`HE F()RM AIS I )I(;1"I 11
<br /> IN,STRUCITON FOR 1111,I)CAI.,AGI"rW II-S
<br /> The state c=ndca°kxacamd storage tank identification number is composed of the:two digit county number, the three digit jurisdiction
<br /> number. the six digit facility number and the:six"digit tank member, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. The faci
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