|
INSrRUCIIONS]FOR(X)MPU--MNG FORM*W
<br /> GENERAL 114917RUCP[ONS.
<br /> 1, One FORM x13"shall be completed for each tank for all NEW ISI RMr!S,PERMITCTI ANGE-S, REMOVALS and/or any
<br /> otherTANK INFORMYV171014 CI IANGR
<br /> 1 This form should be completed by either the PE.RfACI"APP LICANT or the LOCAL AGENOY UNDERGROUNDTANK
<br /> N< 'OR
<br /> 3, Please type or print clearly all requested inforn-eation,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF IZORM.-"MARK ONLY ONE.rrFm,
<br /> 'L Mark an(X) in the box next to the item that best describes the reason the form is being completed.
<br /> 1 1 Indicate the DBA or Facility name where the tank is installed.
<br /> I. TANK III SCRIPPION-CMP1,11171 ALL FIEMS-TFUNKNOWN-SO SPPXII?Y
<br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.A1370789),
<br /> & Indicate the name of the company that manufactured the tank(ex.ACMETANX Ml°"<G,).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D. Indicate the tank capacity in gallons(ex.15,000 or 10#X)cic,).
<br /> 11. TANK CON'llWilS
<br /> A. 1. If MOTOR VEMICIA2.FUEIL,check box"I and complete items B& C.
<br /> 2. If not MO'FOR VEHICLE F`UEL,check the appropriate box in section A and complete items B & 1).
<br /> B. Check the appropriate box.
<br /> C. Check the type of MOTOR VIN11,01"FFEL(if box 1. is checked in A),
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C,A,S,#.(Cliernical Abstract Service
<br /> number), if box I is Nor checked in A.
<br /> HL TANK CONSrRUCITON-MARK ONE 1`11M ONLY IWBOX A,B,C&1)
<br /> 1. Check only one item mTYPI1 Of'SYSTEM,'J'ANK MATI'3MIAL, INTE7,RIOR LINING and CORROSION PRo'I'E(.,nON.
<br /> 2. If OTHER,print in the space provided.
<br /> IV. PIPING INIK)RMAIION
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable..
<br /> 2. If UNKNOWN,circle, or if 0111EIK print in space provided.
<br /> 3. Indicate the LEAK I)FTECYION system(s) used to comply with the monitoring requircment for the piping.
<br /> V. TANK IMAK DH:IIFX'IION
<br /> 1 Indicate the LEAK I)ETEX711ON systeni(s)used to comply with the monitoring requirements for the tank.
<br /> VL INFORMA710N ONTANK PERMANENJIM CLOSIff)IN PLACE
<br /> 1, I�SJJM/VFED DATE I.,AS-r USED-N401SIll/YFAR(January, 1988 or 01/98).
<br /> 1 ES11MATED QUAN'ruy of IIA7ARDOUS SUBSTANCF remaining in the tank(in Gallons).
<br /> 3. WAS'TANK PI11ED NVI'111 INE 1CI'MATERIAL? Check'Yes'or'NO'.
<br /> APPtICAMf musir SIGN AND DAIE ITH!IAO RM AS INDICKMID.
<br /> 1114,S717RUCMON FOR'nW,1X)C.AL AGINCHIS
<br /> The state underground storage tank identificatiorl 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. 'ne county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (91(1)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 munber,please leave it blank,
<br /> rr 1,S'ITIERaSPONSIBIlIff OF 111B U)CAL AGENCY IIIAT INSPWV511111 1?ACI1.X1`YI,'0 V17RH-N 1111z
<br /> ACCURACY 017'111E IN11X)RMJV11ON- 77HI 1,C){A1, ,R 11TE CO
<br /> , 1,AGENCY IS R13SPONSIBIET FO MPLERION 017171111
<br /> 'LOCAL AGENC Y USE ONLY*1.NFX)RMNnON IX)X AND FOR FORWARDING ONE R)RM'A!AND C. °E
<br /> Is -Ir(s)T011fE IsOtIX)WINN ADDRESS.
<br /> 9ENIM OF"1FORNIA
<br /> S
<br /> 19 CONTROL BOARD PATE WJV]T,R RE-SOURCU
<br /> C/o sm.mlp.S.
<br /> D)VrA PROCIMING awmlk
<br /> P.O.BOX 527
<br /> PARAMOUN17,CA 90M
<br />
|