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IN'S'I[RUCIIONS FOR COMPLFFINGOM B.
<br />1. One I^C RN1 "El' shall be completed for exalt c nk (rr =alk NFW I FIRM "ISI; Iyl,Ivf,Ii.1' C'IIAt;iFS, R17,O AL and/or any
<br />other'IANK INFORAINnON CILANGE
<br />2. This form should be completed by either the c ,A 1, A ,i .° C"V C ,.+.atIHR4. R(yiil D TANK
<br />INSPFXTMK
<br />3. Please type orprint clearly all requested
<br />4: Use d hard point wrifingoistrument,you ac;", is,< ..>. � ,
<br />TCJI OF FORM; *MARK ONLY ONE LII2 *
<br />1. _, Mark an(X) in the box next`to the it,. m ihat t--,v dcscrilrIcs flhc vcason !)",e :;_t,>i is bsing f.o nn4€ ,,,J
<br />. Indicate the DBA or 'Facility nainc wher; t1w ., . _. is „istiatii°.S;
<br />I. TANK DI SCRI ITO - COMPLEFF, ALL YI-EMS , IF t.:;,364 ihy -S() S1,. t !y
<br />A.„: Indicate owners. tank ID # - It t#v.= i.,_a t i k,,.ti,.;+,,. _.xai: is w�ceE a i„i, ti.rni.r ;rsa i,s.y ..aF,w tai,C (ex, .FL3,..i799).
<br />B. Indicate the name, of the co parry than .__air ... wai.,, ths, is-,,0k , .. AC MIt I eA Ni.,, sok-G,).
<br />C. Indicate the year the tank %yas instal' ('
<br />I); Indicate the tank capacity in gallons (ex, 2>,€ Dv ,., ,,s YJ ctc"),
<br />IL TANK CONTFIVIS
<br />A. 1. If MOTOR VEHICLE I UFL, check box t and h.s m I''t & C,
<br />1 If not MOTOR, VIs11IC LE FUEL, ,, checai ye af,ipropriazte, box in ,,cction A and, e. ,tea .e.w i.° .s sr & D.
<br />B. _ Check the appropriate box.
<br />C. Check the type of MOTORE11]C; Ls 17"U r, (it box I is cl,cvsCd it
<br />tl: i'raztt-Cecheina.calnazne of the hazardous substancesvorcd ,n sig and :_,K (v,..,tiricsil Abstract d;srv&e -
<br />number), if box 1 is No,r checked in ,
<br />III. fl € C O I'ICIICo [ O - MARK ONE NIS ON1,Y IN IX)as' A,, IS, C° A, II
<br />1. Check only one item in T z PE'yF` S;VS F sI, TANK ,I. ,11"RI i L, ..' , t ; i Fa and t ,i P IIIyC ION Piit i YH YI N
<br />2: If OTHER, print in tire .peace provided,
<br />IV. PIPING INFORMATION
<br />1. Circle A if above ground; circle U if undcrground, and 6rclw both
<br />2. If UNKNOWN, circle: or is OTHER, print in a, ash provided.
<br />3. Indicate the LEAK I3hTI-,Cm`IJO sv-sti. (sa .-sed to c., ztN wits, , lire it >ia,.aOo a fvr the fnpar,d.
<br />V. TANK LMK DFI'Ia,C:IICIi
<br />1. Indicate the 11L.':A ild"11;C:`IION system(s) usedto comply w;.iil. fln r. i„<;x a , r ,aiirLinenis for the tank.
<br />VI. INPORMA310N ON TANK PURI IIk"N IIN CIA-NSED IN a t AC
<br />1. ES11MATED i ATF I ST h €.t - MoNN`l II YI.=13C (tan a t '988 or . EI84 .
<br />2.I Z'Ilait TI.-J.) QUAN'TI°Iy of IV,.ZAIPD0US SIMSI'?.NCEI ., roti i x, in, + ,..,?. , (in . ,,i0io's),
<br />3. WASIANK ILII-I'D WITH IiN'IsiRT it ATERI A.I,, C'* e Yes' or N()
<br />APPII(ANT MUSiF SIG 'UME -TIE FOIVA AS Ii `DIC;7t. i 7i.4.
<br />INI�TIMUC11ON FOR'nRI I,C) I,OENC:° I.r,I
<br />The state underground storage tank identification number is ccyn iressed` ofthe two dsTit county nun,a)er, the three digit jurisdiction ;
<br />number, the six digit facility number and the six digit tank € umber. `flea ,,.-ounty and jUri!,di_tiratnunibcty ,are predetermined and
<br />can be obtained by caking the State hoard (916)739-242L The facility number mn � t be the v �v as shown inforrn.” , The
<br />tank number znay be assigned by the local agency-, however, this nurnh r rnus_ aF a, .rncricra and cannot contain an alphabet, If
<br />the local agency prefers the State Board to assign the tank muml u , 3 ca cave �.
<br />I'1`IS°IIIERF.SPIIE°IBHI'I° 0I7TISL(JfW, TIRE `I"Iair
<br />ACC-URA('Y OF IRIE Its FO It"I1C1ivl`. `IIIc? LOCAL GF,,:t C " IS III c,"EIJ`=aSIBLI FOR T! IE t°C1iiIPLE'l O III= 11III
<br />'LOCAL AGENCY USE ONIUM' INKYRMA17ON BOX AND FOR KDRAI ylCiyING ONE' FORNI 'A* AND AfiSO(3XFED
<br />MRM 'W(s)'M11111 FOILOWING ADDRESS.
<br />SrXI'll OF CALIFORNIA
<br />I`XfE VIT T( RFSOURCIN C O ITZOL BOARII
<br />:/o S.W..I-1'a:s.
<br />I.O. FIyyO�X�sp 527 ,C
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