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IDIS I"RUC'I`ONS FOR C O " <br /> CFIFNE U 0 <br /> 1. One FFC1FCM"B"shall be completed for each tank for all N PER 11,PE C I G S, OVALS and/or any <br /> other T `10N CHANGE. <br /> or '.,NGE. <br /> 2. This form should he completed by either the PERMIT APPLICANT or the IDCAL AGENCY Y U 713 C"s O1.TND"C" <br /> JNSTWI'OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making"3 copies.. <br /> P C1IF ONLY CI w <br /> 1. Mark an(X) in the box next to the item that best describes the reason the torah is being completed. <br /> 2. 1 Indicate the D13A or Facility name where the tank is installed, <br /> 1. TANK DES VI`ON-COMPTHIM All.T'I`FF -IP UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank Fla#- If there is a.tank number that is used by the owner to identify the tank(ex.A1170789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME"TAMC MFG.). <br /> C. Indicate the year the tank was installed(ex. 198'1 . , <br /> D. Indicate the tank capacity in gallons(ex. ,000 <br /> or 10,000 etc.). <br /> Ii. TANK CONrFNI',S <br /> A. I:. If M(Y.1 OR VEHICLE FUEL,check box"I and complete items B &C;. <br /> 2. If not MOTOR VEHICLE DUEL,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 VBFIIC ,L'F^`1IEL(if box I is checked in A). <br /> I). Print the chemical name of tete 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 C3N9J'R tt'J1ON A n'EM ONLY IN BOXA,11,C.&13 <br /> 1. Check only one item in TYPE 0171 SYSS"I"E ,°[`ANK MATERIAL,i:N'I'ERIOR LINING and CORROSION FBiZ€)"i EC"I"10N, <br /> 2. If OTHER,,print:in the space provided. <br /> IV. PIPING INMRMA71ON <br /> 1. Circle A if above:ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,C)WN,circle; or if OTHER,print in space provided; <br /> 3. Indicate the LEAK DI;TI C'I1ON system(-,)used to comply with the monitoring requirement for the piping. <br /> V. TANK LI IC DISI '.. ON <br /> 1. Indicate the LEAK IFI;I`EC 1°ION system(s)used to comply with the monitoring requirements for the tank. <br /> A17C?N ONTANK PERMANPM.11Y CL0SFD IN PIACE <br /> L ESTI I7 D DA11,1'LAST USED-?lRf NTII/YEAFC(January,1.988 or 01/88). <br /> 2. I~:S"TIMN D QUANITFY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons) <br /> 3. WAS TANK FILLED W17111 INZ RI'MAT'"I LIAL? Check'' cs`or'NO' <br /> APPLIc ANr"musr siGN AND DATFnim FoRm AS i ic;A°I IF , <br /> IN:;MUCTION MR TIII?LOCAL AG <br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction <br /> number,the sax 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)731-2423. The'facility number trust be the same as shown in form"A". The <br /> tank number may be assigned by the local agency; however,this number mast 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 /> IT IS 17113 RESPONSIBILITY OF II?LOCAL AGFNcYi7jmr INSP F,(®TS'17II:FFAC;II TI"f p vERiFY'niE <br /> A O F'17II:?INFORMAITON. 371E LOCAL AGENCY IS RESPONSIBLE3 IiO 111E?CEI PLUIION OF`I71I <br /> 'LOCAL AGENCY USIA ONLY* IFCI CFN BOX ANDIFIL IF R AIZI DINCI ONE FORM'A*AND ASSOCIM117D <br /> IFC1 "Ir(s)TO'17 FOLLOWING ADDRFS& <br /> , ,NJT,-OFFI li <br /> SI'NI7?WATER RIFE, U CIS C ONI'ROL BOARD <br /> C/o&W.E --Ps. <br /> ISA"I"A PROat&SING CIX11Alk <br /> P.O.BOX 527 <br /> PARAMOUNr,CA 90723 <br />