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INSI'R(TC'HONS IIOR CC}MPU11TNC3 FORM'Er <br /> GFNERAL INSFRUC:pIIONSe <br /> 1. One FORM "I3"shall be completed for each"tank for all NI, PERMITS,PER l'01 NGES, REMOVALS and/or any <br /> other TANK INFO ITC}N CIIANG <br /> 2. T'his form should be completed by either the PERMIT FINE" "or the .f)CAI,AGENCY UNDERGROUND'i.A <br /> INSI$ <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point wnting instrument,you are making 3 copies.' A <br /> F OF FX)RM.*MARK ONLY ONE rIEW <br /> L Mark an (X)ifitheb6k next to the item that best describes the reason the fora is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK F'}I< I1ITC}N_ I,rrF?ALL mus_IF uNxNowN <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.AI170789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D} Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 11. TANK CONIIWrS <br /> A. 1.If M(XI'OR VEHICLE FUEL,check box I and complete items B &C. <br /> 2. If not C}'i`OR VEHICLE FUEL,check the appropriate box in section A and complete items B& D <br /> II. Check the appropriate box. <br /> C. Check the type of MO7I'OR VEHICLE F'L;EL(if box 1,is cheeped in A). <br /> D� Print the chemical name of the hazardous substance stored in the tank and the CA.A.S. .(Chemical Abstract Service <br /> number),if box I is NCII`checked in A. <br /> III. TANK CONS',17RUC31ON-MARK ONE 1 ONLY IN BOX A,I3,Ce&I} <br /> L Check only one item in TYPE OF SYSI'EM,'I`ANIC MjV.l'ERIAL,INTERIOR LINING and CORROSION PROTEC CION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMAITON <br /> 1. Circle A if above ground; circle t3 if underground;and circle both if applicable. <br /> 2.` If UNKNOWN,circle;or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I.Ff,A DE'1 .e ITC}N <br /> 1. Indicate the LEAK DE ON system(s)used to comply with the monitoring requirements for the tank. <br /> INPORMNIION ON TANK PER NEN 11Y CIAXSE0 IN PLACE <br /> 1. ESTIMATED DA`.[`E I.ASI`USED-RhC.IN`11-1/YEAR(January, 1988 or 01/88). <br /> 2. 0S`I`l MA`I'I:;I>QUANMTY of IIA7 ARDO S SUI,1STANC;E remaining in the tank(in Gallons). <br /> 3. WASTANK FILLED W1111 INI.,Kr TRIAL?Check'Yes'or'NC:)'. <br /> APPLICANT IC° SI°SIGN AND DATA 11E,FORM ASN' T ID. <br /> LI ON`MR111111 LOCAL ACEI NCIEES <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. 7'he county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)733-2421. '€'he facility number must be the sante as shown in,,fo 'A". 'Ihe <br /> tank number may be assigned by the local agency- <br /> , however,this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State hoard to assign the tank number,please leave it blank: <br /> rr IS TME RIN; NSI[3 CPI 111E IDCAL AGINCY 1,1 T INSPECTS 11113 FACII TY}VERIFY TI E <br /> AC,°CU OF`ITII'IN17ORMN110N. 11113 IAX:AI,AGENCY IS R13SPONSIBLE FOR nIII C 1ON OF 77113 <br /> AGENCY USE,ONLV INFORMATION BOX AND FOR IURWARDING O `A!AND ASSOCIA111,13 <br /> FORM-Ir(s)TO 11113.FOLLOWING ADDRESS. <br /> IMAI I?C}Ir CA1117ORNIA <br /> SrXIM WATER RESOURCES CONTROL I <br /> C/o&W.F-11.ps. <br /> li}A'pA PROCESSING CF1V117R <br /> P.O.BOX 527 <br /> P OU TI',CA <br /> 0 <br />