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INS'PRUCnONS FOR COMPLEPING,FORMW <br /> GlIN13RAL I LI IONSc <br /> L One FORM"F3"shall be completed for each tank for all NEW PV I. PERMIT CIIANGES, RINOVAUS and/or any <br /> other TANK INMRMATION C IANCiF– <br /> 2. This form should be completed by either the PERwr APPuctmor the LOCAL AGENCY UNDERGROUND TANK <br /> SISI <br /> � 3. please type or priest clearly all requested information. <br /> d. Use a hard point writing instrument,you are making 3—copies., <br /> TOP C)Tt K ONLY ONE 1`11W" <br /> 1< h ark an,( )in the box mesa to the iterm that best describes the reason the fo is being ccaartpleted. <br /> 2. Iddicaf ihet DBA or Facility name where the tank is installed. <br /> Tw TANK D 1.16 _ .COMPLUM?ll-HUMS_IF UNKNOWN <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the bink(ex. l B7Q789): <br /> B. Indicate the name'of the company that manufactured the tank(ex.AClviF:'TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10, etc.). <br /> TI. TANK W ,, <br /> A. L If MOT°C1TC VEHICLIi FUEL,check box 1 and complete items B&C. <br /> 2. If not MC>'t'C)F2 VEMIC LE FUEL,check the appropriate box in section d4 and complete items B adz D. <br /> B. Check the appropriate box. <br /> C. Check the type of M(?'FOR VEHICLE F UE1(if box 1 is checked is A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A:S. . (Chemical Abstract Service <br /> number),if box 1 is N(Yr checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE ripm oNiy IN Box A,Fi,C&I) <br /> 1. Check only one item in TYPE OF'S SF'I?,hT,'tANK MATERIAL,INIURIOR LINING and CORROSION 1"RO "C`I'ON. <br /> 2. If OTHER,ER,print in the space provided. <br /> IV. PIPING INFORMAIION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If 1.TNKINNC)WN,circle: or if C)T'IIEF-print in space provided. <br /> 3. Indicate the LEAK LDF"s -EC171ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK 1311 TC)N <br /> 1. Indicate the LEAK D - Un <br /> ON system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK i ERMANF MMY CLOSIM IN PLACE <br /> E <br /> 1. ES11MATED DAT..,LAST USED-MON"I'II/YF:AR(January, 29or 01/88): <br /> 2. . FSFIMATED QUAN11T Y of IIA7'.r�ItI7OU SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANFC TILL II) IT`LL INT IVI'MATERIAL?Check°`acs'or;NC)'. <br /> �APPIICANT MUST SIGN ANF)DWYE 111E FORM AS INI1 ). <br /> 'RUCI7()N "I'I W, .C)(:AI,A(;EN(°.FI?S <br /> The 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 the six digit tank number. The county and jurisdiction numbers ate predetermined and <br /> can be obtained by calling the State Board(916)739-2422. The facility number merit be the same as shown,in form "A" e <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 /> rr LSTM RESPONSIBRXITC)IVIIIE LOCAL AGENCY`11IAT INST' -IS IIID FA(3LrrYT0 VERIFY11111 <br /> ACCURACY OFTIIE INMRMN170N. TIJE I.,OCAI,AGRINCY IS RESPONSIBLE TL'I'I T C:()MPLU11ON Of'111E <br /> *LOCAL AGfit USE ONLY" 70RM TION BOX AND FOR FORWARDING ONEFORM'A'AND&S , aI D <br /> FORM"T3*(s)TO 11II3 1701.1,OWING ADDREVS. <br /> SrATE OF CA11FORNIA <br /> sm L-P.S. <br /> P.O527 <br /> PARAMOUNI7,CA 90M <br />