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INS`IRUC"11ONS FOR COMPTHIING>[k)R *Ir
<br /> 1, One FORM "11"shell be completed for each tank for all NEW E ITS,PERMrI'CIIAt4GVS, REMO AI and/or an
<br /> €ether.I"ANS INFO "11()N CHANGE
<br /> 2. 'Dns fore shcadd be completed by cither the p`FAtMTl.'APPI1CANr or the .)(AL AGENCY UNDERGROUND TANK
<br /> IN SPI:C7I1) ..
<br /> 3, please type or print cicazrly all requested information,
<br /> 4. Use at hard point writing instrument,you are making 3 copies.
<br /> `I'C)P OF FORM.*MARK ONLY ONE rimm,
<br /> [, Mark an (X)in the box next to the item that best describes the reason the form is facing completed.
<br /> 2. Indicate the C aI e\or Facility name where the tank is installed,
<br /> L TANK DI:WITO -COMPIZIM All,1 E S-11t UNKNOWN OWN-;SC)SPIXIFY
<br /> A, Indicate owners tank I)#-If there is a tank number that is used by the owner to identify the tank(ex.rAB707391.
<br /> B, Indicate:the name of the company that manufactured the tank(ex.ACME`1;rkNY MFG,).
<br /> C', Indicate the year the tankwas installed (ex 1987).
<br /> 1). Indicate the tank capacityin gallons(ex.25,000 or 10,000 etc;).
<br /> 11. TANK C:ONI`1�,N"IN
<br /> "l. If M(Y)'0 R VEIIICLE f JEL,check box I and complete items B & C-
<br /> 2. if not MOTOR VEHICLE,,F U1 L.check l the appropriate box in section A and complete items C) &1)'.
<br /> B. Check the appropriate box,
<br /> C",. Check the,types of Md)'I"OR VI TITC"LI;1tt71,L(if box I is checked in A).
<br /> 1), Print the cbetr ictal name of the hazardous substance stored in the;tate and the C:,A,S. . (C°laernacaal Abstract Service
<br /> number), if kaon I is NOT checked in A.
<br /> IFI. TANK K(X)NNT R'U`C3IC')N-MARK ONE r.1EM ONLY IN BOX A,B CI&I)'
<br /> 1. Check only one item inTYPE 0 sY,%,"E M,TANI 14IA"113 RI AL,IN'ni RIOR I<ININC,i and (':(. IZ RC)SION PR(')"I`IsC`17t)N.
<br /> 2 If 0711(7,R, print in Phe space provided.
<br /> 1. 'Circle A if above ground;circle U if underground" and circle both if applicable.
<br /> 2 1f UNKNOWN,circle; orif 6)`l"I ERS print in space;provided,
<br /> 3. Indicate the LEAK DITTI CrION system(s)used to comply with the monitoring requirement for the piping.
<br /> . TANK 11 AIC 11LrITX7I1()
<br /> L Indicate the ,I f1i{DE1. -C rIt"7N system(s)used to comply with the attoaitoring requirements for the tank.
<br /> V1. INF01MA11014 ONTANK PI41t N1 N L1'"(I A)S a)IN PIACE
<br /> E
<br /> L I,5I'TM .1I.f.) I.1ATE IASI'USED w MONT'"I'II/YEA R(.ianuary, 1,988 or 01/88),
<br /> 2, I SI"1M.NrI,a.i)OU A'°tT`I°1"Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons),
<br /> . WAS TANK FILLED WITI I INE"RT MATERIAL? Check'Yes`or'No '.
<br /> SAI PIAC" T"MU,91',SIGN AND DNI'I,?'11,111 X)RM AS IMICA110.
<br /> IN4;1'RU(711(): 1r()IC 1111,LOCAL AGHN(IHS
<br /> 'Die state undergroundstorage. tank identification member 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. The county and jurisdiction numbers are predetermined ,and
<br /> can be obtained by ailing the State Board (916)739-2421. The facility number must be the "same as shown in "A". The
<br /> tank number may be assigned by the local agency,however, this namber,must he numerical and cannot contain an alphabet, If
<br /> the local agency prefea,the State Board to assign the tank number,please leave it blank.
<br /> I'F IS `I1E,RE,SW) SIB11X1,' 011 1 a I1)(AL AGENCY111AT I SEC I S°H ITT FA0111T TO VERIFT 111H
<br /> ACCURACY C)r'11I1a INFORM 1110 . "11IF LOCALAGIN, (7Y IS RINPONSIBLP FOR11111('C) P1 110N OP 11111,
<br /> 'IOCAL AGEN(TY USE ONLY*I 1 1 I°IC) 1)FOR FORWARDING ONE ITT R *A*AND +AIaSC.1C.IN11
<br /> FO -Ir(s)TO 71111 IZOILOWING aADD RRS.S.
<br /> STWIT"OF CALMRNIA
<br /> C/o& .Lt P.S.
<br /> P.O 527
<br />
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