Laserfiche WebLink
Adak <br />IN,51RUCHONS FOR COMPIXIING FORM "LI" <br />GENERAL I SI° .IG"1` ON <br />I. One F(JKM "I3" shall be completed for each tank for all NEW PERMN Pl Rmir " CHANGES, <br />Cather TANK INITORMNFION 01A CJLI. <br />2. 'I'hisform, should be completed by either the P17RWr APPLICAM.r or the I. :AL AGENCY Y [.l <br />PIX" M <br />3. Please: type or print clearly all requested information. <br />4. Use a hard point writing„ instrument, you are making 3 copies. <br />TOP OF FORAL, "MARK ONLY ONE, MAP <br />L Mark an (K) in the boa next to the iters that best describes the reason the form is teeing complet <br />2. Indicate the DBA; or Facility name where the tank is installed. <br />1, TANK ISIS LION - C O ` I.PI'i:s ALL MIMS - IP UNKNOWN m -So SPBMr1r <br />A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the ta' <br />II, Indicate the name of the company that manufactured the tank (ex. ACIME TANK NM G;.) <br />. Indicate the year the tank was installed (ex. 1337). <br />D. Indicate the tank capacity in gallons (ea. 25,000 or 30,000 etc,). <br />II. TANK C O II4 !'S <br />A. L If O`FO1L EHICLI,. FUEL, check., box l and complete items B & C. <br />2 If not MOTOR VEHICLE FULI ,,, check the appropriate box in section A and complete items l <br />B. Check the appropriate boa <br />€:. Check the type of mC)rOR1,1 1LI 1' °°,'IJEL (if box 1 is checked in ). <br />D. Print tire chemical name of the hazardous substance stored in the tank and the C'>A.S. . (C;hemica <br />number), if boa 1 i NOT checked in A, <br />M. '17ANK C ON LIf;".110N - MARK oNE ni'm ONLY IN BOX A, A C< & D <br />1. Check only one item in TYPE OIT Y s FM, 'pANK MKITSRIAL,,INTERIOR LINING and, COI; <br />2, If C?"i ER. print: in the space provided. <br />PIPING ON] IO <br />1. Circle kR if above ground; circle U if underground; and circle both if applicable. <br />2. If UNKNOWN, circle; or if OTIIERprint its space provided. <br />3. Indicate the LEAK DF'.[' i(,"IION system(s) used to comply with the monitoring) requirement for i <br />V. TANK L FAK DINIX711ON <br />1. Indicate the LEAK DrIfTEC"1IION system(s) used to comply with the monitoring requirements for <br />I. INFORMNITON ON TANK PERMANE11MM CIDS11D INPIACE <br />1, EMMATED DKI'F I.ASF USED - MON TH/Y A t (January, 1958 or 01/88). <br />2. ESTMIXIED QUANIM of HAZARDOUS DOD SUBSTANCE remaining in the tank (in Gallons). <br />. WAS 'I'ANK F° alb wrm INERT MA1111MAL,? Check 'Yes or 'NO . <br />1I g ' SIGN AND DA 111 ' ' IL? FORM AS INDICA110. <br />IN,5FRU(T11ON FOR 11111 LOCAL AC;I C"H—zS <br />The state underground storage tank identification number is composed of the two digit county number; <br />number, the six digit facility number and the six digit tank number. < The county and jurisdiction numb( <br />can be obtained by calling the State Hoard (916)7.39-2421. The facility number must be the same as sh <br />tank number may be assigned by the local agiency, however, this number must be numerical and cannot <br />the local agency prefers the State Board to assign te tank number,: please leave it blank. <br />I"C IS um S Ni IIT " of " 'Ilii LocAl, ACENCY"1 IAT INSPE ' I ? I?A( L TI'Y I ) <br />FORM -11-(s) 170 "ITIS FOILOWING AL)1S ESS. <br />I A A PROCHMSING CE ITT <br />P.O. BOXg-� 52'7 <br />i UNr, CA WM <br />