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INS-FRUCHONS FOR C0.A4PfXTING P'ORM -W
<br /> GENERAL INSTRUCTIONS,
<br /> I. One FOWN! "13"shall be completed for each tank for all Nf,,'W PEiRMI'I'S,Pl:,.Rmrr cnANGEs, REmovAuS and/or any
<br /> other'TANK INFORMATION CHANGE
<br /> 1 'I his form should be completed by either the PFRMrf0APPI1CANFor the Da"..ACTI.-,NCY UNDFRGROUND TANK
<br /> INSPFCFOR.
<br /> 3, Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making I copies,
<br /> '17OP OF FORM: 'MARK ONLY ONE rn.,w-
<br /> Mark an{,V) in tl%, box nt".Nt m 1,11c i',=ul ni best describes ic, the form is being completed.
<br /> 1 Indicate DBA or monc vO-.n, the lank is instaflc,='
<br /> L TANK 1)1,:S(RJVIION-COMPLE113,ALL'T'I'E WL, IF UNKNOWN-:-,Z,411CIIN
<br /> A. Indicate owners tank 11) # - If there ;i;a lank number that is Msc I"by"the owner to identify the tank (ex.A1370789).
<br /> B. Indicate t?,e name of the company tha, as,�mufacturcd the tank .,:.ACME TANK MFG.).
<br /> C. Indicate year the tank was installed ( K. 1987).
<br /> D. Indicate the tank capacity in gallons(cy ',000 or 10,000 etc.).
<br /> It. TANK(X.)NIT.WIN
<br /> A. 1. If MO'I'OR V1.111CLE, FUEL,check box I and complete items B& C.
<br /> 2. If not MOI.I OR V1.111CLE FUE.L,check the appropriate box in section A and complete items B& D.
<br /> 13. Check the appropriate box.
<br /> C. (,heck the type of MOTOR VEHICIXI"MEL(if box I is checked in A),
<br /> D, Print the chemical nanic of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service
<br /> number), if box I is N01'eliecked in A.
<br /> III, TANK C,0N,5I'RIJCJION-MARK ONE rnlw ONIM IN IXYX A, 14,C&1)
<br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, IN71`13RIOR.LINING and CORROSION PRO'11-1'(.-FION.
<br /> 2. If O'HIER, print in the space provided.
<br /> IV. PIPING INFOWNXION
<br /> 1. Circle A if above ground; circle U if underground, and circle both if applicable.
<br /> 2. IfUNKNOWN,cii-cle: c?rifO'].'Ill-',P, print inspace proVided.
<br /> 3, Indicate the LEAK DI"'FEC7110N s;vstcm(s) used to comply-with the monitoring requirement for the piping
<br /> V. 'FANK LEAK DF,`11',(7170N
<br /> L Indicate the LEAK DE-I.FC110N sy-stern(s) used to comply with the monitoring requirements for the tank.
<br /> VL INFORMATION ON TANK PERMANW, 11M CLOSED IN PIA(',E
<br /> 1. F-,SJ1MA'I'ED DATE LAST USED-MON'FlI/YEAR(January, 1988 or 01/88).
<br /> 2. E911MA11.71)QUANITIT of HAZARDOUS SUBSTANCI. remaining in the tank (in Gallons).
<br /> 3. WAS TANK FILLED Wl'I'll INFRTMA`FERIAL? Check 'Yes'or'NO'.
<br /> APPI.I(AN1.7 Ntusr sia,,I ANI)aNnintE izoRm AS mmNlrEn
<br /> INSTRUCTION lFOR'nIE IDCAL AGENCHIS
<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. 'I'llie county and jurisdiction numbers- are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. 'I'lle 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 isnui REspowBuInly OF TuE t-.(KAL AGFNC-Y 111ATINSP11"'S 11111"17ACIIXI'Y'110 WRIFY'nIE
<br /> ACCURACY OF111F,INFORMATION. 711H IA) AI.AGFN(Y IS RESPONSIBI,E FOR 111E COMPLETION 017 111E
<br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE IZORM*A"AND A.W)CIA1ED
<br /> MRM-Ir(s)11)THE IkHADWING ADDRES;%.
<br /> SIWIT OF CAIJFORNIA
<br /> 91WIT,WN!I.,R RUNOUR07,S CONTROL BOARD
<br /> DATA PROCESSING(AIN11W
<br /> P.O.BOX 527
<br /> PARAMOUNI,C:A'
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