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<br /> 1. One Ii'dlRN "I3"shall be completed for each tank for all NFW PV-RW,IIN PF,,Rmri,CHANGIN, REMOVAIS and/or any
<br /> otherTANK INFORMA1101d 01ANG1
<br /> 1 This form should lie completed by ether the i ERMTI" PPI CANT or the I.DCAL AGI]INICY UNDERGROILWYEANK
<br /> I :SPI1 "1`012.
<br /> 3 Please type or print clearlyall requested ted information.
<br /> 4. Use,a hard point w°icing instrument,yi:)u are making 3 copies.
<br /> I`CaI$OF FORAC WARS:ONLY ONE F17 U4'
<br /> L Mark all (X) in the box next to the €tears that beat describes the reason the form is being completed.
<br /> 1 Indicate the Li,'4 or f=acalr,s,namewhere the tank is installed.
<br /> I. TANK DESCRIVITON-COMPHaV 1U,1,I I 1 S_.IF 1J 'N Ca ' -SO SPEX,7FY
<br /> A, Indicate owners tank 11) # -if there is a tank number that is used by the owner:to identify the tank(ex.A1370784).
<br /> B. Indicate tine name of the company that manufactured the tank(ex.ACMFI'FAN MIaC.),
<br /> CIndicate the year the tank ryas installed (ex. 1987).
<br /> 1:f. Indicate the tank capacity in gallons(ca,'3l,£ or 10,000 etc.).
<br /> IL TANK CONIVNIN
<br /> A. I. If, C.Y '()R V1:111 LE FUEL,check box I and complete items I3&C.
<br /> 2. If not mo,rO€C VI-1110.17.F al,,check the appropriate box in section A and complete items B& D.
<br /> 13. Check the:appropriate box
<br /> C. Check the type of N40TOR IIICLL< ""TEL(if box 1 is checked in t1).
<br /> Dc Print the che$nicat name of the hazardous substance stored in the tank and the,C.A S. .(Chemical Abstract Service
<br /> number),if box t is NOT checked in A.
<br /> III. TANK C1O ,'�;1°RU aIION_.MARK ONE r[124 ONLY IN IX)X A,II,C°&13
<br /> 1F 1. Cask only one item in TYPE O Sir SI T',WpANK NINFERIAL, INTERIOR LINING and CORROSION 'IZOTEC:°I°1ON.
<br /> 2. If OTHER,print in the space provided,
<br /> IV. PIPI C1INM= R 1t°i'I1t
<br /> I. Circle A if aebcaveground;circle'U if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle., or if(TRIER,print in space provided.
<br /> 3. Indicate the L STC 1"1L:I7I C"1'ION systent(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LMK DUITI)CITON
<br /> 1. Indicate the 11-;AK LIF fi 1(71-1 ON system(s) aasecl to comply with the monitoring requirements for the tank,
<br /> 1. E S I I AIT,,D 11A`F IA1ST USED-MO,\I'i / l:,A (January, t or 01/88).
<br /> 2, LSTININ11 D C1UAp7 l"IY of ILctZARIJCII.S SUBSTANCE remaining;in the tank(in Gallons).
<br /> 3. WASTANK 111, .ED WITH INTtIRT MA"1ERTAL?Check'Yes' or'NO.
<br /> Appuc r musr SIGN AND D I ?`DTII'?FORM AS INDICNIED.
<br /> I TS I'RI C. C1 U R,IT, g LOCAL AC1I';NCIE:
<br /> The state underground storage tank identification number is composed of the Mo digit county.number. the:three digit jurisdiction
<br /> nunrt�cr°,the six diet facility number and the six digit tante number, Tire 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 form'W" The
<br /> tank number may be assigned by the lcacai agenciyz however, this number must be'numerical and cannot contain an alphabet. If
<br /> the local aency prefers the State Board to assign the tank number,please leave it blank.
<br /> 17171S 1111?Rl iffiS ONSI I[T"T"Y"Op"ITIE L OC .X AGI C Y 1717.`I S'FC"Ili 1il? rrACyIL 'M VERIFY`I"[I?
<br /> ACCURACY CII °I7 k?I FORMA`I'10N. 'IIID LO(AL-AGENCY IS RESPONSIBLE FOR 1111f C OMP1.I 71O 01711111
<br /> 'LOCAL AGENCY USH ONLY"INFOR t 111 AND IUR IsORWARDING ONE FORM'A"AND A.°` C XIED
<br /> IURM*i1"(s)`170 111E.IlOUDWING Tia S,
<br /> C/o .i x ILi'w1i.
<br /> Pd]i.I3O X 527
<br /> P OU I',CA 90M
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