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Is 1 CCt1"IONS IlOR a:;£)MPLITI ICI rC) "11"
<br /> C~L"sN3 CAL INSTR "Cr t'1CL1 ;
<br /> t.. One 'Vk B`shaft be completed for each lank fccr all NEW PIs `P, U U�,'E f S, WIMOVAIX and/or,my
<br /> =th .=yL INF4'()1CN1-A1'1:0N C fAL1GU
<br /> y '1 his t.,nn should be corripictcd by either the F'FRm 'Al PLIC"�A `I'or the LOCAL AGHNCY LItgDIg,ICC:i12Clt)ND TA.
<br /> INSPU(.11A.
<br /> Please mre or print clearly all requested information,
<br /> l,Jlse a ,>,,:3;i point wriling inst:rurnent,you etre rrakniig 3 copies,
<br /> TOP OF 1)(Wh6ir -N&ARK ONLY ONE TITNP
<br /> cl,,,i k an (X)in die t 6x next to the,item that bet describes the reason the form is being toafsphi ed,
<br /> 2, lnl-di ue the s.ali:s or Facility mame where the race is instaHe€I.
<br /> 1. TANK I)ISX'RIP I{:III-C;OMPLI1"Hr AIJ,irrim1-IF UNKNOWN-S0,SP1X'TF1Y
<br /> A, Indicate owners tank 11) # -If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> 13. Indicate the name of the company that manufactured the tank (ex,ACW°Ir`iNK I ITO.).
<br /> C, Indicate the.year the tank was installed (ex.1987').
<br /> I,r, Indicate tkte tank capacity in gaklons(ex. 25,M)or 10(Vt etc.),
<br /> U. TANK C'C) IENI
<br /> I. b NNIOTO12 VCHIC l,i FUF; 1,check box I and complete items B & C.
<br /> �. Ifa;rt MOTOR"s yUlIC"t_L Y 1 ,check the appropriate box in section A and Complete items 14 I?.
<br /> Lar Chock the appropriate box,
<br /> C% CheckthetyPe ofa4iC?'rC1II v1".111C',`LE I°L7 .t,(if box 1 is checked in A).
<br /> D, pa:rrt the ch t�rcal name rsr tarn. qtr, ,°r�sL�, sui,rst°s r :str>red in the. tank and the C:.�.5. .(C`Irc ictal Abstract �c ice
<br /> 111, bVN CCILISI tir.",I'1ON-MARK Ca lle nim ONLY IN BoX A,B,C
<br /> 1, ('heck cafly acne here in-FVPF t,I:,ItYS FA"lANK III"f ILIAL,WITTIOR LINING;and CORROSION f'I 0Tft('I'l N,
<br /> 3, If 041 IFRprint in the space provided.
<br /> ]VPIPING WUORKNI10N
<br /> 1, Circle A if aboxc ground,circle CI if underground; and circle heath if applicable.
<br /> 2. If UNKNOWN,caacl or if OTHEIR,print in space provided.
<br /> 3. Indicate the LEAK used to comply with the monitoring requirement for the piping.
<br /> V. TANK LE.W DINVC"1 C1N
<br /> L Ird.,.axe the LF IC DE-111,'(71'I0N systena(s) used to comply with the monitoring requirements for the tank.
<br /> VI, INFORMYVION ONTANK PERMANIENILY CLOSED IN PLACE
<br /> ;. 1 1 a3'tCA f`F1t) JXT LAST Ltfs1,1.1- M0,V11I/ I.-AR (January, 7985 or 01/88).
<br /> 2. T:`,'"IIMA 7'I;I)QUANT r1" of IIAL11 DOUS Ialwtllll`I'ANCT'remaining in the tank.(in Gallons).
<br /> 3. WAS I`A�` K FI LLE'D WITH IN ff r MiVI RIAL,?Check ` €s'or'NO'.
<br /> APPI(AW,`r mum SIGN AND DK113`TTE FORM AS I 1) VI I),
<br /> IrO °I'IHIT L.C)(L,AG]W(II t
<br /> s he state underground storage tank identification number is composed of the two digit county number, the:three digit jurisdiction
<br /> nurnfirer; the six digit facility number arra; the six digit tank number. 1lie county and jurisdiction nutubers are predetermined and
<br /> can be obtained by calling the titrate Board (916)7'39-2421, Tbe facility number must he the same as shown in for "A". `:I'he
<br /> 1,,,mk ritanber rimy he assigned by alae total agency; howeacr,this number timst be numerical and cannot contain an alphabet. If
<br /> t,,e local agency prefers the State Board to assign the tang;number,please leave it blank,
<br /> ff I;S1711,ICIC C) SI IITSI"I'0I,,'I1IE ,CI(., I.AGENCY'°11IA °INSPI1Ct`!x 111E FAC:ILrI ° RIF Y`llui
<br /> AUXAZAC'Y OF 11111 INK)RUIN110 . 71111 IMAL AGENCY IS UNPONSIBLE FOR"17IE COMP1131110N OVI I ;
<br /> '1,()C I.AGEWY USE'()Flim'"INFOR SHON BOX D FOR FORWARDING ONE FORM"A" 7 ASSOCINITID
<br /> TURg1-B-W TO-111H FOLLOWING A 3I)I2 ' .
<br /> XI'Y`1"f OF CALIFORNIA
<br /> P,O.BO 521
<br /> PARAl rataNF,CA a a'"t 3
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