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IN. _ I3 C) s FOR COMPLFnNG,FORM"FIw <br /> GENERAL 1 UC1711ONS <br /> 1. One FORM"I3"shall be completed for each tank for all NFW It I? I.'S,PERMIT IT CHAN ie, RENIOVAUS and/or any <br /> other TANK INFORMA31ON CIFANCYF7 <br /> 2. This form should be completed by either the I"I:rRM r APPLICANTor the I.,OCAI,AGENCY UNDERGROUND TA <br /> P ` <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3,copies. <br /> TOP 017 _ RIC.ONLY ONE rn " <br /> 1. Mark an (?C)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> L TANK I F- N- IPME;ALL IIMMS®II*UNKNOWN-SO E7 <br /> A. Indicate owners tank II)# - If thea is a tank'number that is used by the owner to identify the flank(ex.A1370789) <br /> B. Indicate the name of the company that manufactured the tank.(ex.ACME 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 10,000 etc.).' <br /> II. TANK CONTENTS <br /> A. 1.If MOTOR' FIIIC€,I FUEL,check box l and complete items T1&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE I71JEL(if box 1 is checked in A). <br /> I). Print the chemical nacre of the hazardous substance stored in the tank and the C.A.S. .(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> IFI. TANK C ONSr° U ,<C)N®mARK ow rim C)NI.I`IN Box ii,IS,C&I) <br /> 1. Check only one item in'TYPE OF SYS ..,M,TA K MATERIAL,FV..I`P.T2IOR LINING and CORROSION PROTECTION. <br /> 2. If CTIA R,print in the space provided. <br /> 1V. PIPING O A ON <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If.UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DEUMCITON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DIq717lON <br /> 1. Indicate the LAK DE`lT'.(`TION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INIURMATION ON TANK PERMANEN11M 0 10 IN PI-ACE <br /> 1. ES11MATED,DATE VAST USED- ON`1`I I fYE (January, 1988 or 01/88). <br /> 2. ESTIMATED QUA °ITT of HAZARDOUS SUBSTANCE remaining in the`tank(in Gallons). <br /> 3. WAS TAMC FILLED WrIll INT IVI'MA'. +TZIAL?.Check 'Yes'or'NO', <br /> APPLICANT SIGN AND I)A'I3 e°1.T cFORM AS INDICATED <br /> S TRU C)N R IIIT?LOCAL AGENCIES <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 are predetermined and <br /> can be obtained by calling the State Board(916)739-2421. 'Ile facility number must be the sante as shown in force"A". Tlae <br /> tank number may be assigned by the local agency, however,this number crust 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 /> Tr IS THE )Nd °1 OFTHE I-II;I AGENCYTHAT INSPWIS 171111 FACIIXff TO VE °L`3II? <br /> ACCURACY OF 11 1111 INFORMATION. ITIE LOCAL AGENCX IS RESTONSIBLE FOR 11111 C.OMPLHI1ON OI7°IIIE <br /> OIDCAL AGENCY USENi )` ATIE3N BOX AND FOR FORWARI)ING ONE FORMA"AND `10 <br /> ORM 4r(s)TO 11111 FOI1,OWING,ADDRESS. <br /> STAID OF CALIFORNIA <br /> STAIN,WATER RFSOURCES C O 'ROBOARD <br /> /E)S. ,F?I?ps. <br /> P.O.13OX S27 <br /> PARAMt UNP,CA 90M <br />