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Ii ,1iF`82L1C'I 0N,S 17OR C°C MPLE l G E "E3s <br /> GENE L I IZCI,.'I('N& <br /> 1, One I'C3RM"L3"shall be completed for each tank for all NEV ISI? YI'S,PHRMrr CIIANGIN, REMOVAI S and/or any <br /> other TANK INFORMA71ION CHANGE. <br /> 2, This fora should be completed by either the PERmrr A l i NI'or thcLO(Yd,AGENCY >'NDERGRC)LIND TAN <br /> INSP .I"C)L. <br /> 3: Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 ccpd�s\ <br /> TOP OF FORM: 'MARK ONLY ONE TITN' <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being con pletc,d: <br /> 2. Indicate the DTIA or facility name where the tank is installed. <br /> . TANK DI7.` . P`I`IC) -C."C). E E`1`E:ALL rIE S m IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank II)# -If there is a tank number that is used by the owner to identify the tank(cx,AB70789). <br /> II. Indicate the name of the company that manufactured the tank(ex.AC I EI?TANK 17G.). <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 /> FI. TANK C ONO I S <br /> A. 1, If MOTOR TOR VrIIIC I.11:,FUEL,check box I and complete items II c&C. <br /> 2. If not mff.rOR VEHICLE, FUEL,check the appropriate box in section A and complete items B&D. <br /> 13, Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box 1.is checked in A), <br /> 13. Print the chemical name of the hazardous substance stored in the tank and the C.A.S. ; (Chermcal Abstract Service <br /> number), if box I is NOT checked in A. <br /> III. TANK C ONS: UCTIC)N- K ONE M.W ONLY IN BOX A,IT,Ca&I) <br /> 1. Check only one item in'TYPES OF SYSTEM,TANK MATERIAL,IN° E'RIO LINING and CORROSION PRO'I`1,'C`I1ON. <br /> 2. If OTIIETZ,print in the space provided. <br /> IV. PIPING INFORMA11ON <br /> 1, Circle A if above ground; circle U it underground;and circle both if applicable. <br /> 2. If UNKNOWN, circle;or if C)'TFII°12,print in space provided. <br /> 3. Indicate the I,I::AK DI-71 3'C rICSN system(s)used to comply with the monitoring requirement for the piping. <br /> V. °IANK I13AK F)ISFE(®E7C)N <br /> 1. Indicate the Ial.t K DUI'I C71ON system(s) used to comply with the monitoring requirements for the tank. <br /> . INIURMNIION ON TANK PERMANINILY C IA)S I}IN PLACE <br /> 1. 1;S"I'IMA'I1"D I)A7:'I3 LAS I'u sED- C)NTII/Yl AR(January, 1.988 or 01/88.). <br /> 2. F-5.11MA7'ED C, UANTPIN of IIA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INEu idrlAll, I..2 Check 'Yes'or'NO' <br /> AppucAmr musr SIGN AND D 1°Ea 71TH!17ORM ASI IC.A"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 nix digit tank number, The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (9I6)73e1-2421. 'The facility number must be the sante 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 Stage IToard to assign the tank number,please leave it blank. <br /> I'll'IS"IHE RESPONSIBUX17Y OF 11lti IAWAL AGENCY Y 711AT 1NSPE 311E FAC: IN TO VERIFT 11II1 <br /> ACCURACY OP ITIS INFrC7RM 1"1C)N. 11111 LOCAL AGE:aNC Y IS RESPONSIBIE[DR"111 COMP1,1111 N OF 111E <br /> 'LOCAL AGENCY USH ONLY'INFORMAITON BOX AND FOR IDRWARDING ONE FORM "A."AND ASSOCIA110 <br /> FOR 'B'(s)TO`I IFI FOI.A) G ADDRESS. <br /> NII?OF C".A1111C) to <br /> ST`AF`F WNII,,R RESOURCES C O "ETC)1 BOARD <br /> C:/C7 S. .F?.T.?P.S. <br /> DATA PROC'.IISSING 0INIER <br /> EO.IX)X 527 <br /> PARAMOUNF,CA 90723 <br />