|
INSUIUCIIONS FOR COMPLMING,FO *I3*
<br /> GENERAL INSMUCIIONS-
<br /> 1. One FORM"I$"shall be completed for each tank for all NFW PFRM]rl.N, PER rr CT NGF-S, R 3 OVAI s and/or any
<br /> other TANK INFORMATION C IANC1
<br /> 2. Thisformshould be completed by either the PIA 17 APPUCANr or the 1,0CAI,AGMCY UNDERGROUNDTANKAGM ,
<br /> INSPECPOPL
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point waiting instrument,you are making 3 copies.
<br /> TOP OF FORM."MARK ONLY ONE MW
<br /> 1. Mark an (3C)in the box next to the item that best describes the reason the form is being,,.completed.
<br /> 2. Indicate the DBAor Facility name where the tank is installed..
<br /> 1. TANK DF–SR TON-&)mPjvrLzAiL nims- a uNKNowN-So spavy
<br /> A. Indicate owners tank IIS#-If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> B. Indicate the name of the company that manufactured the tank.(ex.ACME TANK MFG.),
<br /> C. Indicate the year the tank was installed(ex. 19€47).
<br /> D. Indicate the tank capacity in gallons(ex.25,OW or 10,000 etc.).
<br /> 11. 'TANK COMTiNrS
<br /> A. 1. If MOTOR"ti"1<1IICI..I: FUEI,,check box 1 and complete items B&C.
<br /> 2. If not MC3`I"OR VI;IIICLE FUEL,,check the appropriate box in section A and complete items B& I)
<br /> 13. Check the appropriate box.
<br /> C. Check the type of MOTOR VIIICI,E LUE1,(if box 1 is checked in fi).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C:.A.S. ,(Chemical Abstract Service
<br /> number),if box I is NOT checked in A.
<br /> In. iANK wNsrRLJC"I°oN-MARK ow rl oNi y IN BOX A;t.I,Cis&D
<br /> 1. Check only one item in TYPE OF SY91EM,TANK 1\4ATI31(IAI„I. `EItIOR I,INING and CORROSION P1ZL?` E(—,.I1ON.
<br /> 2. If C) EI;,print in the space provided.
<br /> . PIPING
<br /> ATTON
<br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or if fJ`I'HER,print in space provided.
<br /> 3. Indicate the LEAK DM: 1J O system(s)used to comply with themonitoring requirement for the piping.
<br /> V fANK I.I�.AK Df 1700
<br /> 1. Indicatethe LEAK DEI'E. , C N system(s)used to comply with the monitoring requirements for the tank.
<br /> VL INFORMATION ONTANK PER ANMvr,I` 177(MOSED IN PIACE
<br /> I. I ,I`F;I)DATE LAST USED- ON"ITI/YY.AR(January, 1988or 01/88).
<br /> 2. ESTIMATED QUAN'11TY of IIA7A,ItDOUS SUBSTANCE E rem ining in the,tank(in Gallons).
<br /> 3. WAS'I°ANK 17I111,"D'Vi i ni jNE In,m/V.rE, IAI,7 Check`Yes'or V43%
<br /> APP11CAN17 MUST SIGN ANI)DW117 7111E FORM AS INDICAr
<br /> NS°ri(IIC T10NTIM,LOCA1,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)739-2471. '1'he facility number trust 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 State Board to assign the tank number,please leave it blank.
<br /> ACCURACY Cllr 71111 INFORMATION. °ITI13 I,OCAI,AGENCY IS I SPO SIBI H FOR 7.T-IE C(IM.PL,L?IlON OF T7IF
<br /> "I L,AGIINCY USE ONI, )RIVIN`ON BOX AND FOR.FORWARDING ONE FORM*A" ASS(X ``D
<br /> I -W(s)TO TIE FOI.1,0WING ADDRIISS.
<br /> SFATF OF CAIJFORNIA
<br /> S`1AM,"WXIMR RESOURCES CONIROL BOARD
<br /> C/o sem T Ps.
<br /> I)A'I°A PRO(_M.SS1NC$(M 1 M
<br /> P.O.BOX 52?
<br /> PARAMOUNP,CA WM
<br />
|