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<br /> INS UC11 NS FOR GOMP1,17,17ING to lir
<br /> GENERAL INSTRUC 'I NS:
<br /> 1. One 'Cit" "13"shelf be completed for each tank fbr all NEW PIER .S,PE?2 I", 'DAN T .','RYJMO AI.a and/or any
<br /> otherTANK .)R "I'IO CHANGE
<br /> 1 This forma should he completed by either the PFRWl'APP11cAlsrr or the LOCAL A6FNf Y UNDERGROUNDTANK
<br /> INSP , 1yI1
<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 OF,11OR .'MARK ONLY t C'Ni� 'ww
<br /> 1 Mark an (X)in the box next to the item that best describes the'reason the form is beim;completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> I. TAN E—SC 2IV11ON-OOMPLITI"T�ALL I'ITI MS-117 UNKNOWN-So STECIFY
<br /> A� Indicate o ners tante ID -if there is a tank number that is used by the owner to identify the tank(ex.A1374799)
<br /> B. Indicate the naane of the comp=any x.,at manufactured the tank (ex.AC:lrtt "I"ANN FG.),
<br /> C, Indicate The year the wunk was in staffed(ex, 1987).
<br /> 1). indicate the tank capacity zn gallons(x, 25 V)or Mood etc.).
<br /> IF, TANK C0N1TtN`T
<br /> A, 1, If MCYI'OR VFIIICL F p I TT,check box 1 and complete items 33&C.
<br /> 7.If not MOTOR VEIIIC T,,�p'U L.,check the appropriate box in section A and complete items 3& II.
<br /> B. ('heck the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE I I FUEL i L(if box 1 is checked in A).
<br /> 17. Print the chemical name of the harFrlous substance stored in the tank andthe C;.A.S .(Chemical Abstract Service
<br /> number),if box t is '4'O 1'checked in A,
<br /> III. TANK CONS RU P ON-MARK ONE I'IISY(ONLY IN I3OX A,I3,C&I)
<br /> L Check only one itcrn inTYPE 01'Sy'STI"e1,T,r K MATERIAL, IIti URIOR LIMING and CORROSION PROTF,t"I'IO .
<br /> 2. If OTHER,print in the space provided.
<br /> IV. PIPYNG INFORMATION
<br /> 1. Circle A if above ground; circle U if underground, and circle both if applicable.
<br /> 2. If UNKNOWN,ciac;f; or if C2'1'HER,print in space provided,
<br /> 3. Indicate the LF'—,NK DI"I FX-1100 system(s)used to comply with the monitoring requirement;for the piping.
<br /> V. TANK I,MK DF 1?C170N
<br /> 1. Indicate the L,I„,AI{1111"I FlC'DOld sruteni(s) used to comply with the monitoring requirements for the tank.
<br /> V1 IN[IO A'IIO ON'rAN PII3i° AKI'M[I. f° fa3 INPIAO
<br /> 1. I?:i"T`I'YSA'tED DXI'I: 1 QST USED D-l ONT II/'it;AR(January,19819 or 01/88
<br /> 2. ESTIMNI'il )O ANTFI Y of HAZARDOUS S SUBST NC✓E remaining in the tank(in Gallons).
<br /> 3. WAS'/; NK FILLED TI'll FTEI2"i''LkVIT—RIAL?Check'ices'or`NO'.
<br /> PI CI' 1 IS IO ANT)11I 11i'1dti;FORMI AS N I I .
<br /> INS17RUO11ON P01111111 LOCAL A(3ENC IES
<br /> The state underground storage tank identification number is composed of the task,digit cs Unty 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 Iry calling the State Board (916)7319-2421. The facility number must be the same as sho m in form "A". The
<br /> tank nur ber may be assigned by the local agency-, however, this"number"must be numerical and cannot contains an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it Blank.
<br /> I'T'IS TIW, ESPONS31[p3tIXLY 0I7°niF LOCAL AC,I N(-Y Tl1XI" NSPEAT1,-i'I'T E FACI1, IX) ?2II'Y`T'tII;
<br /> ACCURACY OF TiTF It°F . A`nobie '11113 LOCAL AGEN(TY IS RISPONSIBLE FOR 11113 COMP11ITION 01717111
<br /> 'LOCAL AGENCY USEONLY'INFORMYVIION 13OX AND I II IeOR ARDINGa ONE MRM*A*ANDASS £[)VnzD
<br /> FO 'I3"(s)`1" 1'III31 7IJ O II (3 AI)1 RE&S.
<br /> SFXIT OF C ,IIN) IA
<br /> C/CI S; d.II I p.,&
<br /> POC 13OX 527
<br /> PARAMOUNF,CA 90723
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