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<br /> IN'n'I RTX17LtNu"S I ) ('C) PLLr a Pl)RM 1r
<br /> 61:.NFJ.I3.AF,FN 1: U(`,'110NS.
<br /> 1, Ons fl0IlM "I3" shall be completed for each tank lI r all NEW E n ,PERMT17CIIANGES, REMOVALS and/or any
<br /> „l. Ibis fc er should be completed by either the PE TY A PLICA l'or the LOCAL AGFN(,Y UNDFRGROUNDTANK
<br /> ellen $ :1e or ro1iit fine tris all rerguaa,ed anfcartraat,can,
<br /> 4. Use " lield taunt w rit.ng;arnst�r snen£.you are sicking 3 copied.
<br /> .17011 OIr I )PIlle a Al��ONTLY ONE ya'f '
<br /> 1, darken; (N)in the i ox next:to the here that best describes the reason the form is being;completed.
<br /> 2, Irndaectic the DBA,or Facility ty nanre where the tank is installed,
<br /> L TANK IJIC ' F"II N-C OMPI TrE ALL ITEMS-W UNKNOWN-- )SPECIlry
<br /> A, Indicate owners tank ID #-1f there is a tank number that is used by the owner to identify tire tank(ex.A]370789).
<br /> II. lgdicaf the ria€tae of the company that manufactured the tank(ex.AC I`?TAN MFG,),
<br /> C, Inditat=r the year the; tank was installed (ex.1987),
<br /> . . Indicaac,the tank capacity in gallons (ex.25,000 or 10,(? etc.).
<br /> 11, TANK(X)]cNTNrS
<br /> A. I. If MOTOR I"'JIT11;I LIf L,cheek box I and coartplete itettrs B& C.
<br /> ,If notC)"1'C;aR'V17111CLE,t L';F,' „check the an ropriate box in section A and complete items B DJ
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VE11101 FUIEL(if box 1 is checked in A).
<br /> D, Print the chemical nameof the hazardous substance stored in the tank and the C,A.S. .(Chemical abstract Service
<br /> .f.
<br /> ruaal�rr)y to E�a'xx T is y,tp1 checed it,.A.
<br /> FII.. TANK f.a i.JSI I,fC'[10N- l%RK ONE;Flys CiNTL IN I-X-)X A,,13,C&L)
<br /> t, Check#n, ,rune dera in I-YPE O SYS 1 fs,�s,`1 ANN IMATFMIAL,ISS I I`sRIOR LINING and CIC)Tt12t3SION 'i2C7T C"1'100,
<br /> 3, If 01`111:iis,print in the space provided,
<br /> 1V PILING INIX) II( ON
<br /> 1. Circle A if above ground;circle,C7 it underground; and circle'bath if tapplialble.
<br /> 1 if UNKNOWN, circle, or if OTIHIR,print in space provided.
<br /> 1 Indicate the LEA ,D1rl'EC'I10N scctorn(s)used to comply with the monitoring requirement for the piping.
<br /> V. TAMC LEAK DVI'1I(XICJN
<br /> 1, frtdir,we the LEAK 171,i BCDON systems) used to comply with the monitoring requirements for the tarn;.
<br /> 1. I ORMA'I'Tf N ON TANK PFRMANENIIN CLOSED NLAC."T;
<br /> i, usa[f;ly°•r rd Iyivri3 t,,,sS7`u sui)-moN-ril 'FEAR(January, 1988 or 01/88).
<br /> 2, FS','I MA":1'1sI)0UA\7]TIY of HAZARDOUS:SUBST AN l' remaining in the tank(in Gallons).
<br /> 3. WAS I ANIC T`ILLFII) WITH INE r MATERIAL? Check'Ycs'or'NC)".
<br /> APPI IUAMF a FU91'SIGN AND DA17T'I I?FORM AS IND10V110,
<br /> V110,
<br /> INSIMI.IC17ONT FOR°111If LOCAL AGEN01i1-9
<br /> Th,, crate undcrg Lound storage.tank:identification number is composed of the two digit county number,the three digit jurisdictions
<br /> s,nmher. [Inc six digit facility number and the say digit tank number. `11te county and jurisdiction numbers are predeterndned;and
<br /> au be a;1,taincd by callin,the State Board (916)739-2421. The facility number must be the same as shown in form„A". 'I'lle
<br /> lank n"ay he assigned by ttre local agency; however.this number must be numerical and.cannot contains.an alphabet, If
<br /> the _, ry „—efers a_p�st.a e Par assign the tank number,please leave it blank,
<br /> I T :IS°1`111?R ,S ONI SIBILTI Y 014"HIII I,00M., DCII?:NC Fr 1` d F i I z klF:x PAC L °TMJ I<LFI" `°IE
<br /> AC'.'URA(.'7'OFTHE HE INIX)FI `ION. 11113 I C'AL AGFNGY IS RENP)NSIBIAi FOR 711F COMPIXTITON OF ITIE,
<br /> 1LC CNC AGENCY USF ONLY*INFORMS17ON T,1OX AND FOR FORWARDING ONE MRM°A" I)A'S.' CIX111D
<br /> I^nRM-W(A) p`Ol.hOW N x ADDR R&
<br /> S LA IIH OF CA11F NSA
<br /> SIA'11;W IT'R ROR)URCEN C)N1 C)I RD
<br /> CIC)S. ICC P-
<br /> DXFA PROCIISSING C RN71:°.1C
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