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51 7
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<br /> IN:TMUC CONS MR COMPIZITNO FOR 'IV
<br /> GENERAL TNS7I'Ittlt: C Nis
<br /> 1.. One FORM "I3"shalt be completed for each tank for all NEWPFRm , `'F,*RMf1'C IIANCII3S, : O Al.s ond'or any
<br /> other TANK INPORMXt'I()N CHANGE-
<br /> 1 'I'his form should be completed by either the PFRMl`1'APPI,1(7kW or the LOCAL GT:iW' I)F3IZCITfC UND'I'ANIC
<br /> INSPIR71' R-
<br /> 3. Please type or print clearly all requested information,
<br /> . Use a hard point writing instrument, you are staking 3 copies:
<br /> 'TOP OF FORM. *MARK ONLY ONE num"
<br /> 1. Mark an (X) in the box,next to the item that best describes the reason the form is being completed,
<br /> 2. Indicate the DBA or pacility name where the tank is installed.
<br /> I, 'IANDFSCr II}ITON-f:OMPI,EAI.M All,17I1:M«IIT UNKNOWN...S(}SM:IT
<br /> A. Indicate comers tank 11) ,# - If there is a tank number that is used by the owiter to identify the tank(ex.AB707S9).
<br /> I3, Indicate the name of the company that manufactured the tank(ex.ACME.I`FANTC MI'Ci.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> I). Indicate the tank capacity in gallons(ex. 25,000 or 10,000 ctc.)
<br /> II.
<br /> '17ANK CC)M11 I
<br /> A. L If 4IC7`IOR VEINC'LE ItTUFL,check box I and complete Sterns I3& C:;.
<br /> 1 If not t:)"I'C)IL VF1IIC1,17 I LFLsL.e cbeck the appropriate box in section A and complete items 11&T).
<br /> B. Check the appropriate brat,
<br /> C Che.ck the;type of X101'OR VET II LF,FUI`.I.(if box I is checked in A).
<br /> D. Print the chemical narne of the hazardous substance stared in the tank and the C,A.S. . (Chemical Abstract `sexvic:e
<br /> number), if box 1 is NO'r checked in A,
<br /> 111. `tri C X)N,'1`RUC`17O -MARK ONE I'MM I'MONLY IN IICIIC A,T3,C;&T)
<br /> 1. Check only one iters in'I'YTI ;C)Ir"a ;SIT 1%2„'IAN t Al ti1AL, I...NI'ERJOI2 I.I ING and CORROSION}RO'I'EiCFIO .
<br /> 2, If O'HIE ,print in the space provided.
<br /> V. PIPING INFORMIMON
<br /> 1. Circle A if above ground, circle I1 if underground and circle both if applicable;
<br /> 2, If.UNKNOWN, circle; or if 071111"IR,print in space provided.
<br /> 3. Indicate the LEAK I)l;1'I>C:'IIC3N system(s)used to comply with the monnoring requirement for the piping.
<br /> V. 17ANK I.I3AIC DULE-711 al
<br /> L Indicate the LEAK D1 rf.:'(I'i0 systems) used to comply-with the monitoring requirements for the tank.
<br /> VT. I:NFO A'I10N ON'CANK PERMANENMY CLOSED IN I"I. (jI
<br /> 1. I,SallMA"11 D D 'I1 IAS"USED-NIC)N'llIJA'E,AR(.January; 1.998 or 01/88).
<br /> 2. ESFIMA-Ti l) OUAN'I'I':i'Y of HAZARDOUS SUBS'1'..ANC111` remaining in the tank(iii C.sallons).
<br /> 3. WAS TANK FRIED Wi'�T"II ENT::.R'I'MXI'ERIAL? ("heck 'Yes'or'NO',
<br /> APPLIC°AN'r MU517 SIGN ANT)I)xm iilf;mRm AS INDI(: 11,11),
<br /> TNIiI'I U ON MR771E 71E LOCAL AGENCIEN
<br /> 11c 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 ilia six digit tank number. 1'be county and jurisdiction numbers are:predc terrnined and
<br /> can be obtained by calling the State Hoard (916)739-242I. 'I'lic facHity nue bee must be the same as shown,in form "A". 'I'lie
<br /> tank number may be assigned by the local;agency: however,this number must be numerical and cannot contain an alphabet, If
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> I'I'IS ME RESPONSIT3II,I'1'Y C)Ir'17E LOCAL AGE"NCY>IITA'I'INSPi.C`i"S'nu?FACaIIJI` 'I`C)VERIFY 11II.a
<br /> ACCURACY€)Ir L 1E INIk)R IIC)N. `I IE F C)C AL AGENCY IS ONSID1.1; )it.'11111 C OMPLEMC)N(3 r`"E
<br /> 'LOCAL AGENCY USE'ONLY*INIk)RMA'17O.N SOX AND 17OR FORWARDING ONfl?R)RM, 'A'A D ASSOC U t'l?)
<br /> FY) *TT'(s)1`0 I"TIF,I LIDWING ADDRESS.
<br /> 91WMI 017 CAt11FO ZrN'IA
<br /> zs.aE?
<br /> WJVM1lR, LY§.fi,,°h, a" g ;, q �x . °t.o�,.J
<br /> ..,
<br /> P.O.BOX 5V
<br /> PARAMOUNT',CA 1AYM
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