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f .T.IG.1'ONS FOR(X)mPijTnNc,itoRm
<br /> I. One IFf.3I2M "I3"shall be completed For each,tank for all NEW INTI 1`S,PERMIT Call G;IES; RE: (1V S and/or any
<br /> other TANK . lC) 'nON CJIIA GP_
<br /> 2. This form should be completed by either the.PlERMIT APPI1CANT or the LOCAL UNDERGROUND TAN
<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 FORhC-*MARK ONLY ONE Tn,?M'
<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 do 'gMity name where thetank is installed,
<br /> . TANK T)EW, IM -`(60 PI111'131All,i`I°IF S-IF UNKNOWN-SO SPFAWY',
<br /> A, Indicate owners tank Ila #- 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 tltat,rnanufactured the tank(ex..A ME TAMC MFG.).
<br /> C. Indicate the year the tank was installed(ax. 1987).
<br /> 1). Indicate the tank capacity in gallons(ex.25,000or 10,000
<br /> ll. TANK G.`C1 ''['w1"s
<br /> A. L If MOTOR V HIC;I,I FUEL,check.box I and complete items I3&C.
<br /> 2.if not MOTOR VEIIIC LI,1 FUEL,check the appropriate box in section A and complete items I3&D.
<br /> B. Check the appropriate box.
<br /> C. Check the t of mC)'I`OR VEHICLE FUEL(if britt 1 is checked in A):
<br /> 1). Print the chemical name of the hazardous substance,stored in the tank and the C;.A.S, .(Chemical Abstract'Sevvice
<br /> number),if box 1 is NOT checked in A.
<br /> M. TANK CONSTRUCNION_ IC ONE 1`112A ONLY IN 3C) ,11,C&D
<br /> 1. Check only one item in'INPE OF SYSTEM."PANIC MATERIAL,IAL,INT IZIOR LINING;and CORROSION PROTECIION.
<br /> 2. If OTHER,printinthe space provided.
<br /> . PIPING INFORMNITON
<br /> 1, Circle A if above ground;circle U if underground;and circle blah if applicable.
<br /> 2: If UNKNOWN,circle; or if C)`IIIER,print in space provided,
<br /> 3, Indicate the I.I::AI(I)k,TF:X'I'IC3iv system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DH11X170N
<br /> 1. Indicate the LEAK 131:,1'1 (710N,system(s) used to comply with the monitpl-ing requirements for the tank.
<br /> V1. INFORMAIION ON`I `EIR ANE"N1 €vI )S'1I1)IN PIACE
<br /> 1. Tiff II AIT.D DATE IAST USED-M01,T]:`II/YEAR(January, 1988 or 01/88).;
<br /> 2 ESTIMATED QUA<TITI'Y of I7AZARDOU SUBSTANCE remaining in the tank(ire Gallons):
<br /> 3. WASTANK FILLED WITI I Ia°mI;I1TMATERIAL?Check'Yes'or'NO'.
<br /> AI'pu ASI mun SIGN AND )A711i°17117 FORM AS I DICAFIR .
<br /> The state underground storage tank identification number is composed of the; two digit county number, th8 three digit jurisdiction
<br /> number, the six digit facility number and the six:digit tank number. The county and jun.sdiction numbers are predetermined and
<br /> can be obtained by calling tate State Board (916)739-7122, 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 /> I'LsnmRFsK)Nsrm.,rrY OF11tE LocAL Lo' AGINcynim,iNspI" l 1'III?lfwa i..,1 'ID VliltIFY 17111
<br /> ACCURACY OF ITTE INTIO A°I'ION. 71113 I,C :A,A(;r,,N(,'Y Is IF-S. NSIBLY!FOR ITIP C!OMPIJTI10N OF TIII3
<br /> "LOCAL AGENCY USE ONLY' IFC) NnO AND IK)R I7C)IiWA11I)I G ONE FORM'A7 13 'SC 119)
<br /> FO W13"(s)TO111171 IF01:1,0 I GI Ai3DRE Sa
<br /> A'I'I?O F CAI, ),I EA.,.<, i � a F�, �',�k. a 'n �� � )
<br /> rx ca fo S.W.P-F-P.S.
<br /> P.O.13ox 5V
<br /> 'PARAMOUNr,CA WM
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