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<br /> i ,z TTC ON S MR COMP11TIING F()RM 1W
<br /> GENERAL INSMUCE[OW
<br /> 1. One FO "B"shall be completed for each tarn for all NEW PEW.B,PERMyr CH C 11% 38,I3A�C) and/or any
<br /> other`i ) 'FIO C I C3
<br /> 2. This form should be completed by either the 141RIarr PP11(7d4T or the LOCAL a1CNE'std UNDERGROUND TANK
<br /> I SPEC I#
<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 FORN--WARK ONLY ONE MW
<br /> 1. Mark an (3C)in the box taut to the:item that best describes the reason the forth is being completed.
<br /> 2 Indicatelft DBA or Facility nacre where the tank is installed.
<br /> I. TANK I)L1-1S- 61N,-COMPTHM,.€ll,rm -nz uNKNowN-so F
<br /> Xxpy
<br /> .k•: :: w,.,, -:- t
<br /> A. Indicate owner's tank II) #- If there is a tank number that is used by the owner to identify the tank(ex.A1370789).
<br /> B. Indicate the name of the company that manufactured the tank (ex.AC E TAN MFG.).,
<br /> C. Indicate the year the;tank was installed (ex. 1987),
<br /> I). Indicate the tank capacity in gallons(ek,•25,OW or 1.0, etc.). -
<br /> 11. TANK C ONI"Ts" I
<br /> A� I. If MOTOR tr HIC H...FUEI,;check box 1 and complete items B&C.
<br /> 1 If not MC)'IOR VEHICLE I UE1,,check the appropriate box in section f4 and complete items B &D.
<br /> I3. Check the appropriate box.
<br /> C. Check the typc'of MOTOR VEHICLEFUEL(if box 1 is checked in A).
<br /> D. Print the chemical same of the hazardous substance,stored in the tank and the CA.S. . (Chemical Abstract' Service
<br /> number), if box 1 is NOT checked in A.
<br /> ILI, TANK CONS UCeHO -MARK ONE 1`11N ONLY IN 136 A,11,C:&I3
<br /> 1. Check only one item in TYPE OF SYSTEIM,TANK Riri"I:'ERIAI,,INTERIOR LINING and CORROSION PROTEC'T`ION,
<br /> 2. If C3THER,print in the space provided.
<br /> . PIPING ISI PITO
<br /> 1, Circle A if above ground; circle Il if underground;and circle both if dpplicablei
<br /> 2. If IIIN`IC.INC)ia N,circle;or if OT II.R,print in space provided.
<br /> 3. Indicate the 1,13A s 1)FTEC"ION system(s)used 11 to comply with the monitoring requirementfor the piping.
<br /> V. TANK LEAK DUMCIION
<br /> 1. Indicate the LEAK I)I;l`I C'FIL7p system(s) used to comply with the monitoring requirements for the tank..
<br /> L. 1N1k)RMX11ON ONTANK PERMANITWIJy C qlt)IN plACH
<br /> 1. T SF'IhIA'I"I0 DATI;b,\S"I USER MON71`IIJ1' !tIt(January, 1988 or 01/88).
<br /> 2. "IMATED C UA-,"I-U-y of IIA7ARITOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS TANTS FILLED WITH II',],'RT NvvI°I:sRIAL?Check'Yes'or`NO',
<br /> APPLICANT MUS`r SCAN AND DA711i 11111?11C) A,9 I I)IC:.dl F[II).
<br /> INSIMUCIION FOR111E LOCAL CiI, C'Ins
<br /> The state underground storage tank identification number is composed of the two digit county number, the,three digit jurisdiction
<br /> number, the•szx 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 /> rr is wERPmoNsiBmay 01-nm wrAE1l it i wr iNspi-ri 7 iil i?A(,,IlrrY TO vERIFY 11111
<br /> ACCURACY OFTHE I.NFORMS110 , '111E LOCAL AGENCY IS RESPONSIBLE FOR 71I13 COMPI.V11ON 017 11113
<br /> *LOCALAGENCY USE ONLY'INFORMAIION BOX AM)FOR FORWARDING ONE FORM` !AND ASSOCW'I'D
<br /> IAC) W(a)TWIME IrCH1, hIC1;t DD r S.
<br /> ' STA17E OF CATIFORNIA ,
<br /> CIO S. .I?I?h.S.
<br /> P.O.Im 521 ..
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