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TNSTrRUCnONS FOR COMP Cs FORM"I#w <br /> GENERAL IN [7 C) <br /> 1. One FORM"£3"shall be completed for each tank for all NEW PERMTFS,PERMIT CIIANGF-S RYWOVALS and/or any <br /> other TANK INFO TION CHANGE <br /> 2. This form should be completed by either the PER lT APPIJCANT or the LOCAL AGENCY UNDERGROUND TANK <br /> S <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> `MP OF ISORM:*MARK ONLY ONE <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK ISL S. IF17ON-COMPLIT1713 AII,I".1'E -IF UNKNOWN-.So SPFCHIIY <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 /> B. Indicate the name of the company that manufactured the tank(ex.ACME 1ANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25, or 10,000 etc.). <br /> 11. TANK K CONIMMI"4 <br /> A. 1. If MO'T'OR VEHICLE FU—F.",,check box I and complete items£i&C <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items I3 &D. <br /> B. Check the appropriate box. <br /> C. Check the type of marOR VEHICLE FUEL(if box I is checked in A). <br /> I). Print the chemical name of the 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 CONSTRUC"IION-MARK ONP FI : ONLY IN BOX A;114 C&L <br /> 1. Check only one item in TYPE OEC SYSI`E3 ,'°ANL; MATERIAL,,I;NFE:R.IOR 11NING and CORROSION PROTEC 110N. <br /> 2. If OTHER,print in the space provided. <br /> . PIPING INFORMA71ON <br /> L Circle Aif above ground;circle U if underground; and circle both if applicable: <br /> 2. If UNKNOWN,circle,or if OTHER,print in_%pace provided. <br /> 3. Indicate the LEAK DET CT11ON systems)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHII_CIION <br /> 1. Indicate the LEAK DI.glC'I'ION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ONTANK PER ANI? fLY CIDSED IN PIACI! <br /> 1.. E,`v`ININI'I 13 DATE ST USM)-M0-%-HI/YEAR(January,1.988 or 01/£343). <br /> 2. ESTI: TED QUA\7FnY of HAZARDOUS SUBS"I'ANC. ,remaining in the tank (in Cxallons). <br /> 3. WAS TANK MLLE D WrITI I1�T?R':1 MA"IT<RIAL?Check'Yes`ac'NO'. <br /> AppucAmr mugr SIGN.AND DATE11113 IK)RM AS INDICAIMI). <br /> S LIC ON FOR 11113 LOCAL.ACWNC'IRS <br /> The state underground storage tank identification 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. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board 0)16)739-2421. 'Ihe 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 /> IT IS 1I1E RESPONSIBlIX17Y OF 77111 IMAL AGENCY'ITIAT INSPBUI TIIIE FACRXIT TO VERIFY1711E, <br /> ACCURACY C.'Y OF IIIR IN 'LION. °I11E IOCAL,AGENCY IS RESPONSIBLE FOR`IIIE?COMPL IION OIt`nIL <br /> *LOCAL AGENCY U'93 ONLY'INFOR A1ION BOX AND ICOR FORWARDING ONE FO "AND ASSOCVVITM <br /> TSO -Ir(s)TO-nIE FOLLOWING ADD 15,S. <br /> I'E OF CALIFORNIA <br /> 517VI713 WAIMR RESOURCTS CONTROL BOARD <br /> c/o S.WnLr Ps. <br /> DArA PROCTL:`&SING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNr,C' <br />