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IN1,TLRXa I10NS FOR COMPT&CI CI ICT "I3" <br /> GENERAL Ilgsi'RUC PIDNS; <br /> 1, One FORM"I3"shall be completed for each tank for all NEW ISE us,PERMIT CHANGES,S, Itl'sMOV and/or any <br /> otberTANK IN17ORMN11ON CIfi IxfG <br /> 2. This form should be completed by either the PE".RMIT APPLI MP or the'LOCA>AGENCY UNDERGROUNDTANK <br /> IN PPCA R <br /> Please type or print clearly all requested information. <br /> Q. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF I "MARK ONLY ONE T°1"I <br /> 1, „dark an (X) in the box neat to the item that best describesthe reason the form is being completed. <br /> 2. Indicate the DTIA or Facility name where the tank is installed. <br /> 1. TANK I31 a IVI TON-C O PL TI"I:ALI,rl .a S-IF UNKNOWN-SO SPECIFY <br /> A, Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.!6]370789). <br /> E. Indicate the name`of the company that manufactured alae tank(ex.ACME TANK F G,); <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 CON"TENIN <br /> A. 1. If MOTOR VEHIC LI:1 FUEL,check box 1 and complete items B&C. <br /> 2, if not MOTOR VEHICLI"s FUEL,check the appropriate box in section A and complete items B &D, <br /> 13. Check the appropriate box. <br /> C. Check the tape of i4IC?`iOR VEHICLE FUEL(if box.1.is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.Q.S. . (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK C:ON .. UCITC9 -MARK ONE MiM ONLY IN I . IT,C'&D <br /> 1. Check only one item in TYPE OF SE'S :ahs,TANTO MKfl;I IAL,INTERIOR LININ and. CORROSION I RO'I"1:;C"C'SON) <br /> 2. If OTI{EIZ,print in the space provided. <br /> IV, PIPING INMRMKIION <br /> 1, Circle A if above ground; circle U of underground';and circle both if applicable, <br /> 2. If t114I;:NOWN,circle; or if C VIER,print in space provided. <br /> 3. Indicate the LEAK IST-11"CTICBN system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DINIM7.11ON <br /> I. Indicate the I FAK D rIiC riON system(s) used to comply with the monitoring requirements for the tank. <br /> 1. ESTIMf1:11.F9 I11!"I:"E LAST USED-MONTH/Y11AR(January, 1.988 or 01/88). <br /> 2. Ei41'IN AIT'.)QI.JAN-rt"I Y of HA7ARDOU8 SUBSTANCE remaining in the tank(iii Gallons). <br /> 3. WAS'TANK FILLED WITH INERT M/ I11RIAL? Check'Yes'or'NO'. <br /> PPIJ(` UST SIGN AND DATE 171F,FORM AS I IC°.e4°T <br /> STZIJC11ON FOR.'ITTE LOCAL AGENCIES <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(916)739-2421. The facility number must be the same as shown in fomes "A". The <br /> tank number may be assiped by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the Sta&e Board to assign the tank number,please leave it blank. <br /> `IS THE 1>t0SNSIBILD'Y OF`III i LOCAL AGC Y THATINSPBM'S71E ICAC. "7f TO,VERIFY 11I13 <br /> ACCURACY OF`ITII3 INFC3I MXPION. °ILII?LOCAL AGENCY IS RESPONSIBLE MR 1 113-CC) ,I ITCTN OF TIIE <br /> *LOCAL AGENCY USE ONLY"INFORMNITON BOX AND FOR FORWARDING ONE?MRM 'A7 AND&.S." •I1!D <br /> FO "Ii°(s)TO-1111?FOLLOWING,ADDRESS. <br /> o XII?CTIA CAMFORNIA <br /> S IVIT<WNIUR RESOURCES CX)NIMOL BOARD <br /> C/o ss. °".h'JTt ps. <br /> P.O.13CiX 527 <br /> PARAMOUNP,C' <br />