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INS-17RUCIIONS POR CC,IMP1.:ETI `C1 FORM*Ir
<br /> 1, One FORN4"t3shelf be completed for each tank for all N1.75v PE.Rmms, 'E1RM 1'C I C iF , RUIMOVAUS and/or any
<br /> 2, This f-ornt shou3d be completed by either the PERIalff APHICANTor the LOCAL AGENCY Cly ERGROUND r
<br /> I?NSPECIX)R1
<br /> 3. Please ttepa or print clearly all requested information.
<br /> 4. Use as hard point writing instrument,you are making 3 copies.
<br /> TOP OF FORA. 'MARK ONLY ONE ""` , "
<br /> 1. Mark an (X)in the tae>x next to the ite n that test describes the;reason the t`ca rri is being completcdi
<br /> 2, Indicate the; or 1"acuity narne where the tank is installed
<br /> 1. TANK DISC RIP11O N"-CYC IZI.`E All.1"C1IMS-IP UNKNOWN-SO SPEn,
<br /> A. Indicate owners tank ITS,# -If there is a tank number that is used by the owner to identify the tank fee A1370789),
<br /> IB.- Indicate the: name of thecompany that manufactured the tank(ex,ACME TYNV..MF(1),
<br /> C. Indicate the year the tank was installed (ex 1987).
<br /> D, indicates the tank caapacity.in gallons (ex, 25(XX)or 10,OW etc.).
<br /> IL TANK C NI1; .1"I
<br /> `'1. if MOTOR V1,111011 FUEL,check box 1 and complete items I3& C'.
<br /> 2. If not h1(;A"C`C'SI1 VEIIIC"LI,f"IJI.,"L,check the appropriate box in section A and complete henna B & t5
<br /> B. Check the appropriate box.
<br /> C. C;hack the type.of MOTOR 4r1,1I1C"LE FUEL(if box 1 is checked in k).
<br /> 17. Print, the c�hcmical name of'the hazardous substance stored in the tank and the C`.r4.4. . (Chemical Abstract Service
<br /> number),if box'1 is NOp checked in A,
<br /> TIT. TANK(X) MUC1`IC)IN_MARK ONE 17111 ONIN IN BOX A,B C:&1)'
<br /> 1, Check only one nern in":1YPE C)I�ISI SIEM,'I's'4:4 °I"I;CIIAL,IIN"1`Tsl]OR LINING and CORROSION PRO1I71C YION
<br /> 2 if 0771ER,print in thea space provided,
<br /> IV. PIPING INFURMA13014
<br /> 1, Circle;A if above ground circle U if underground;and circle Froth if<applicable.
<br /> 1 -If UNKNOWN, circle; or if U11113R,printin space provided.
<br /> 3. Indicate the 1.,EAK D1.`TI.,CI'l0 N system(s) used to comply with the monitoring requirement for the piping
<br /> V. TANK LEAK I3HI1XTP1)N
<br /> 1. Indicate the Lf',A 1)1-11 C"1"O N=system(s)used to comply with the ittonitoring requirements for the tank,
<br /> VL 1NI101MjV110N ONTANK I°ERMA2NTtM11,Y C L SE0 IN+PIACF,
<br /> L UNT"i4 A11"D 1'8:74"1"I;1AS'1'USED-:M0N`11IfY1`.7,A C(January, 1988 or 01/88),
<br /> t L AN1 1"I"I' of AYAFtDOUS 4TJ1351ANCE remaining in the tank (in Gallons).
<br /> 3. WASTANK 1,11,LED Wt"1'11 INf'Wr MA113 IAL? Check'Yes"or,N0',
<br /> API"t.IC" 1' U,t 1".%1G N `I)IA `III 11113 H)RM AS IINT)IC 111D.
<br /> The state underground storage tank identification number is composed of the two digh county member, the three digit jurisdiction
<br /> number, the.six digit factllty number and the six digit tank number. 11re county and jurisdiction numbers are predetermined and
<br /> can be obtained by(ailing the State Board (916)739-2421. The facility number n1ust be the same as shown in form "A', The
<br /> tank number may be assigned by the local agency, however,this number must he numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tate( number,please'leave it blank.
<br /> I`T'-S nun RI„S1 o Nsuilla t"" CAT?uni 1. cAl,AGENCY°I11AT INSPIWI 11113 IA0111" °TO'SERI Y°1T1?
<br /> ACCURACY OF 111H INf?ORMA'I1 N. 31111 LOCAL A(HINCY IS RINPONS11311,FOR1111E ) TSI 1C'I"10N OF"11111
<br /> q.:£ACAL AGENCY I.ISI3 ONLY'I1NTrOR i'I014 BOX AND I IC FORWARDING ONE 1k)R 'Al ANT) ,13NOC;IA 113)
<br /> FO "Ir(s)`I'C)"1111:MA LOWING t1DDROS,S.
<br /> W `I"1 R RES()URC IN C ON"17ROL I ARD
<br /> Cf/CB S,Wn u p.II.
<br /> DATA PROCESSING CHM11ift
<br /> P.O.BOX 527
<br /> PARAMOUNr,CA 1
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