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INSI'RUCI'IONS FOR COMPLEUING FORM'Ir <br /> GENERAL IN, U G <br /> 1. One FORM "T3"shall lie completed for each tank for all NEW PFIR I ,PERMIT CHANGES, REMOVALS and/or any <br /> outer TANK INI-K)RMA'170N CITANGE. <br /> 2. This form should be completed by either the PEEL rr APPLICANT A or the LOCAL AGENCY UNDERGROUNDTANK <br /> NK <br /> INSPECTOR- <br /> 1 Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM.*MARK ONLY ONE M�W* <br /> 1. Mark an(JC)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the IDIIA oe Facility name where the tank is installed. <br /> L TANK.DE>" I7ON- Imi.E II?ALL r.I E -IF uNKNowN-so SIDE+ <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.AB707E19). <br /> B. Indicate the narne of the company that manufactured the tank(ex.A.CME^.TAMC.MFG). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> 13. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> EI. TANK C.'ONI'ENTS <br /> A. I. If MC?'I`OR VEHICLE.FUEL,check box I and complete items B&C. <br /> 2. If not MOTOR VEIIIC.I.1,,FUEL,check the appropriate box in section A and complete items EI&I7. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in 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 NOT checked in A. <br /> III. TANK CONI'J'R 7 ON-MARK ONF rI z . ONLY IN BOXA,II,C;&ID <br /> 1. Checkbritt'one item inTYPt O SYST'I?M,TANK MALT.,ZIAL,INTERIOR 11NING and CORROSION E'ROT C`I°TC)N. <br /> 2. If 6T'I-IER,print in the space provided. <br /> . PIPING ISD 'IION <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 DE'I:EC`I1ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK 1313111CTION <br /> 1. Indicate the LEAK DE I1C°I`ICDN system(s)used to comply with the monitoring requirements for the tank: <br /> IN11?ORMA711ON ONTANK P'L?RMANE .I7:"�CIMM IN PLACE <br /> 1. ESnMNI`E3I)DATE I—AST USE D-MC)NTI-I/YEAI2(January; 1.988 or 01/88). <br /> 2, ESTIMATED QUAN`rITY of IiA7ATtDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TAIv'K FILLED WITE1 INERT MATERIAL? Check'Yes'or'I O'. <br /> APP11CANr MUSr SIGN AND DATE THE FCD )I" 1°92), <br /> INS71RUCUION IZOR'nlE 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.. The facility number must be the same as shown in form"A". The <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 /> rI'IS 11IE RESPONSIBUM OF z LOCAL AGENcy wAT iNsmos um FA 1 - Ru" "IIIE? <br /> ACCURACY C)F'ITIF INFORMAITON. WE LOCAL AGENCY IS RESPONSIBLE FO "I, EEE C:OMPI3?°I ON OI7'n1E <br /> wLOCAL AGENCY USI ONLV I PION BOX AND FOR FORWARDING ONE I?O `A"AND ASSOC:INIFl) <br /> FORM'Fr(s)M TIIE FOLLOWING ADDRI.M <br /> ,)VIE OF CAI.JFORNIA <br /> 13AI A PROCUSSING C 119,171.R <br /> P.O.BOX 527. <br /> P'/! , OUN7.l',CA 90723 <br />