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&!,.,'f"m` . s s`vv
<br /> IPS tit) r
<br /> (GE NNER:.I=IN 5p 13r 310N&
<br /> I. One I°.>t kl "II"shall be completed for each tangy for all NFVPHRMn,S,ISE? r aIAN i , Ifii; t:rICAI 4 acid/or any
<br /> other`FANK INFORMATION CHANGE
<br /> Phis fornn should be completed try either the PE'.R , 'AE�PL1(AA For the LOC L A ENC:; IJI �IiI�6401,T�II)"IAI
<br /> _.x.
<br /> ],!,case ,-w c)r print clearly all s..,ae.s.'e d in400naiioae.
<br /> t 'i, U" a Ina rd'ipeditt wliting;'ansetr lent, you are making 3 Vcsl,:e& s
<br /> '110 C))s I ORIM:'MARK ONIN ONE 171EMM'
<br /> :.
<br /> Mark.an (X)in the bott'next to the item that best describes the reason the form is being;completed
<br /> 2, Indicate the D13A,`or Facility name where the tank is iststmled.
<br /> I. TAN I:I RIFFI4 -COMPIHEu rryms-IIr UNKNOWN O -So SPY9
<br /> indicate owners tank,11) # m If there is a tank number that is used by the owner to identify the tank(ex,A1170789).
<br /> . indicate the name of the company that manufactured the tank,( x.AC:ME'I' MFG).
<br /> , Indicate the year the tank was installed (ex, 1987),
<br /> " ( }.
<br /> I). Irsdicatu they tank capacity to att<>ns ex._25 f�ICI or 1d,t )etc.,
<br /> IL TANK(X)MIT-NIS,
<br /> ,H
<br /> & 1 If 11,1 >'1OR VFITt�LE FUl"IL,check box I and compact items I s C".
<br /> %, If not T�if3°I't'R VEHICLE11-i)I3I,,check the appropriate box in section A and complete`stents B& D.
<br /> & €:.he k the appropriate trey,
<br /> C. Check the type of mcfm VE" IC;LI<FUEL EL(if box I, is checked in A),
<br /> I'r'ish the chemical name of the hazardous substance stored in thetank and the C,A.S.#.(Chemical Abstract Service
<br /> numltm),if box I is NOT checked in
<br /> III. 'rA i (X) S :I,7C;I CII - MARK ONE,r1104 ONLY IN B()X A,B,C;&I)
<br /> i." C:'heck only one item in T PEa OF SY°4il,M<'z"<'NK MATERIAL, I I"I"ITUOR LINING and CORROSION I'I2OTEX"110N
<br /> a?. If CII"ItI> ,prim, it 1t�,space pfovisled,
<br /> ]V, PIPLIN l CFOMA C Fk
<br /> L, Circle A if abaci ground;circle U if underground;and circle both if applicable.
<br /> 1 If UNKNOWN,circle; or if 0-11ILT,print in space proxic ed.
<br /> 3. Indicate the LEAK used to comply with the monitoring,requirement for the piping. _
<br /> V. TANK LEAK DVII "1"IC)I
<br /> , Jrdicaic, the LEAK IFI°l FC`I`lt ie system(s) u,,,cd to comply with the monitoring requirements for the tank,
<br /> VL INFORMA'110N ON TANK PERM tr 1 FN I ; .19?flE,[)IN PIACE
<br /> I?
<br /> i, „5rjNvx.Tru3 1),,vr ST USEID-” OI\Tril/Y A1L(January, 1988 or 01/88).
<br /> 1 F' l'INI ITI) OUAI'v''t'IFY of HAZARDOUS SUBSTANCE"remaining in the tank(in Gallons).
<br /> 3, WAS 1ANK F11,1,F11) WITII INERT MA'IL;VIAL? Check 'Yes'or'NO'.
<br /> APPI.IC:Amr musr SIGN AND DNIE' 11H IX)RM AS I DI'«1191
<br /> INS17RIX7110N FOR71111 LOCAL AGE C I S
<br /> he state untie rground storage tank identification member is composed of the two digitcounty number,the three digit jurisdiction
<br /> number,'the sit digit facility number:and the six digit trick metric>er. The county arses-jurisdiction number;are pssdetermined and
<br /> ,,ss�be obtained by calling„the State Board (916)739-2421, The facility number must be the same as shown in form "A",.17he
<br /> 'ank rttantber may be assig mn d by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the Stale Board to assign the tank number,please leave it blank,
<br /> n,III'1'1111 RESPONSIBILIFFY C F11111ICSCA1,A E C!Y IIINFINSPIX71PS 7711.1 FACILTITTO'S II'°!'I I a ,
<br /> ACC;EIICACI'CII 'L I:�I II'OR `ll,,(,)lq, 'i7 F I C':AI,AC;PN(.. IS IrONSIBIm1g 1�'OR'llili C" 'I,I I'ION OF'17 I%
<br /> *IX)CrAL AGENCY USE,ONLY*INFORIAW110N BOX AND FOR FORWARDING ONE FOR "A�AND A SSOCIf 31-iD
<br /> 1}'C °II"(s)'1 -I°IIEs F011,0I G AI3DRIm,
<br /> S1'A'11i:Clic CALIK)RNI1t
<br /> C/O Ii. .1x Il Il.1s,
<br /> ISA"IA PROCCESSING,CENFIM
<br /> 1'.0,BOX 521 +
<br /> A k�MttUN C A 90,72-3'
<br />
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