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,.., y�ixq,�s. ..,. ,wun- k 3r' .,�-y'M� ',Y yu ..u'e. .i:x,,= ,ni ..,., ct•C l .m}@ .. ,., . a R Ca 1.
<br /> #.N11 R UC. 1ONS ire.?(X)M1`U?T E G if()R '.W
<br /> G1; I°,I L IN517RUCRON&
<br /> 1. One 1 t,aI:1I 11"Shall be;completed for each trick for all NEWPERmas,P14 CI"C11ANG , R111MO I.S and/tsa,any
<br /> , 'Ibis fc rraa should be completed by either the U UC`AMF or the.LOCAJ,AGENCYUNI)ERGROUNT)TANK
<br /> Ilk?St'1''.C"III.,
<br /> 3. Please �;pc or print:clearly ar`y a'i requested information.
<br /> 1, Use to hard Point writing:nstrunlem,you are awaking 3 copies,
<br /> C 3 Olt, RM "MARK NLY ONI,11 "
<br /> 1, Mark Bans (X)in the box next to the ?tens that best describes the reasons the form is being completed.
<br /> . Indicate the D13,,or Fricility narne where the tank is installed,
<br /> L TANK 17 , "1IC N- I LI"I L3 All,UEMS-IF UNKNOWN- B SI'IX
<br /> A, Indicate cnvtaers tank ID # -If there is a tank number that isused by the owner to identify the tank (ex,AB70789).
<br /> B. Indieme the name of the company that manufactured the tank(ex,ACME MFG).
<br /> 1;', ind€carte the year the tank was installed(ex. 1987),
<br /> D. Indicate the tank capacity in gallons (ex, 25,00 or 10,M)etc.).
<br /> W TANK U)NITNI3
<br /> A, I. If\,4,(,)'I'OR VEHICLE Hilt,check.box I and complete items 13 & C;,
<br /> 3,If not MOTOR VEHICLE,PUFF°,check the appropriate box in section A<and`complete items B& D.
<br /> 13, Check theappropriate bey,
<br /> C. (,,,h-;,cs the type of MUR)h,V1,111(1,1 l LI T,ff box 1 is checked in A).
<br /> 1). Prinat the chemical name if the hao-rdous sub:t;a u-e stored in the tank and the (',A,S. . (Chemical Abstract Service
<br /> if box I is N01 chc—kcd in A,
<br /> ITL 'lAN1 CwC.'N'3`IRC.it(7110?d-MARK()NE I`TUM ONLY IN BOX A,,II,C
<br /> 1. Check ck c,nly one item in TYPE 01 SYSTFA4,TANK MATERIAL, IttilETLIOR LINING and CORROSION I'RE?TFC"110N.
<br /> d. if cs"a"xlt?12,pram in
<br /> the space Providect
<br /> IV, PIPING I Ir("RWV1lt)N
<br /> 1. Circle A if above ground; circle U if underground; and circle bath if applicable:
<br /> 2. If UNKNOWN, circle;or if 011I111z,print in space provided.
<br /> 3. Indicate the CIZAI)I"11`C"'1If3N sy°stern(s) used to comply with the monitoring requirement for the piping.
<br /> Y, 1ANK l:f"A191 L ?C1IN
<br /> Indy ate the LEAK D T l CTI1 N ,;,tc ra(s) cased to comply with themonitoring;requirements for the tank,
<br /> H1H IT�: rt'1itI rYOON ON TANK I'Ii 1sIAPIP'.N'I`lN C1,0SUD IN PI. (I;
<br /> . 39911 AITU)DATE LA USE -MONTT3 j -,Xly(January,1988 or 01/88)=
<br /> G. ES1"lNilY111)QL.A TTFY of litl.9.^IZ1 OUS`sUMIUANC;i3 remaining in the tank(in Gallons).
<br /> 3. WAS'IANi FIL,I, li) WITH INE 'i'MATERIAL? ('task'Yes'or'NO'.
<br /> I"IaI.R"AN.i 3tr„t;�I`SIGN.ANI l:aJU Ti°1 II;FORM AS INI3TCA7,17 3,
<br /> NSTRUC: .,N lrt'�rRa '1 HE,U,)0%1,.AGF,NC a'
<br /> 11t, carate underground and stc-sage 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 number, °tire county and jurisdiction numbers are predetermined and
<br /> Can be sarbtained by caning the(state Board (916)739-2421, The facility number must be the sanne as shown in foam'A". The
<br /> task n,antnbwr may be assigned by the local agcatgy� however, this number must be numerical and cannot contain an alphabet. U
<br /> the iocal alanry prefers the State Board to assign the tank number,please leave it blank,
<br /> Ff IS'11111 ICILSPONSH31111' OF'xim I ocAi,ADuNcy,m r IN pests`I al rpt t1.,I`lly,110 WRIFY 11IF1?
<br /> a('X'UPv,(,Y C)tr 71131N )RMA7110N, TUE LOCAL AGFNCY IS RESPONSIBIA31 FORTHE C°Cd :I LET1 014 OF71111
<br /> 1111
<br /> "I,CtCAL AGENCY Cha13 ONLY"INIX)RMNIION BOX AND FOR IaY3RWARDING ONE 17ORMOA*AND A C1INI'I3
<br /> ,OF CALIFORNIA
<br /> C/o S,WnT3x. e
<br /> DS:FA PROCIiSSING C EWE
<br /> P0.BOX 577
<br /> ARA:M()T 1N�lt,CA 9(07-4
<br />
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