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IN;II" LIC.'IIO S TOIL COMPLYqING FOOTA°Eta
<br /> GENERAL INS TECEICII"IONS.
<br /> L One I°C)R "I3"shall be completed for each tank for all NEW PF E ERIArl'CTIA GEA REMOVATIS and/or any
<br /> other TANK INtX)RMA711ON C . GFE
<br /> 1 This form:should be completed by either the PERmyr I'I C A I"or the LOCAL AGENCY U E1II(IRO )TANK,
<br /> ,"
<br /> INSPW()It,
<br /> 3, Please type or print clearly all requested information.
<br /> 4: Use a hard point writing insirument,you are making 3 copies.
<br /> "r ig OF FORM, *MARK ONLY() ?EI7I °
<br /> 1, Mark an (X) in the box next to the item that best describes the reason the farm is being completed.
<br /> , Indicate thb. DBA or Facility name where the tank is installed.
<br /> I. TANK I'3TNCRU-11ON--COMPLIfIll All,EIM S @ IF UNKNOWN-So SPEc-11
<br /> A, Indicate owners tank ID ##,.If there is a tank number that is used by the owner to identify the tank(ex,AB70789).
<br /> F3 Indicate the;name of the company that manufactured the tank(ex.AC,ME TANK d FG,).
<br /> C. Indicate the year the tank was in,611ed (ex. '1987).
<br /> I), Indicate.Clic tank capacity in gallons(ex,2-5,000 or 10,000 etc,).
<br /> 11. 'I.`r1N ()NIEN`I',s
<br /> A,` I, If MCI`Y0E1 VEHICLE FL Cai,,check box I and complete items 13& C.
<br /> 1 If not MOTOR VEHICLEE'L,check the appropriate box in section A and complete items B& D.
<br /> B. Check the appropriate box.
<br /> Chick the type of t`bfiC?"IOR VEHICLE I"IJEL(if box 1 is checked in A),
<br /> D. Print the chtnocal 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(Cosh t.uc-noN-MAIM ONE rPENI ONLY IN Bo ,13,C&I)
<br /> !. (;hack only one item m TYP I OF SYSTI3 ,''ANN INIAI"Eal(TAL, INTERIOR LINING and CORROSION PICC)'T E(7110N.
<br /> 2, If 0`1'1111,',]t,print in the space provided.
<br /> IV. PiP (x II I' A'17[O`
<br /> 1. Circle A if above ground, circle U if umdex ound; and circle both if applicable,
<br /> 1 If UNKNOWN, ci-ele, or if OTHER,print in space provided.
<br /> 3. Indicate the LEAK D I C"I'ION system(s)used to comply with the monitoring;requirement for the„piping.,
<br /> V. TANK LEAK )INIX711ON
<br /> 1. Indicate the L,:.AIC D1 T ('i`l N sNete (s) used to c mply with the monitorin;requiremcnts for the tank.
<br /> I. INFORMIVIION ON TANK PERMANEN11M CIA-)SED D I PLACE
<br /> 1. E9.11MATED ED I)A'€`E: I.AST USED- (J, I/YI:R(January, 1988 or 01/8£3).
<br /> 2. 1,,STIMA111-1) QLiAN7117Y of IIALI\2(7JOUS SUBSTANCE remaining;in the tank (in Gallons).
<br /> 3., r S'IAN{ FILLED fpII I EKI' t'4:PERIAL? Chcck''Yes'yr'NO',
<br /> APPI1(7tMr MUSa`I`SIGN ANT)DNI ? 1EI?TURM&S INDI NI :I).
<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 (9"I6)739-2421, 'Me facility number must be the same as shown in form-„A". 1'h
<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 /> I'IS THE3 RESPONSIBI111Y()it 17I IX)C". AGI (Y TII T"IN.%PE.('I S°I71E?I?A(,'ILrrYM VERIFY TIIE3
<br /> ACCURACY 0I11711E I It() 'I7() . '171E LOCAL AGFNC.Y IS RESPONSIBLE IX)T(THE COMPI1� (➢ OF 17II?
<br /> :AT.<AGENCY USE ONLY"INPORMA'n0N BOX AND FOR Ik)I( ARDING ONE 17ORM W 171,1)
<br /> IX) -I"(s)'"C)'11IE?11()1.,1 ) ADDRE-SS.
<br /> ,91W1711 OF CALIFORNIA
<br /> C/O S. .T E-I".S.
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<br /> I rA I�3(OCI .w : "L IZ
<br /> P.O.p BOX 5(27 .gry
<br /> 0723
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<br /> "Alk,C
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