COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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INS'MUCIIONS FOR C'C.) I'LKI°ING FORA *Ir 3. One I"{)R1°r "B" shall be completed for each tank for all NEW PI., r `,, 1'ERMI'1' 01 TC ESQ , 14FIMOVAI S ard,"=or my other TANK INFOR `n CIIANGF- 2, This form should he completed by either the -PERmrr APPUCAm.r or the LOCAL AGENCY NI)IIiCCAitC)I.TND °TANK INSPWrOR. 3. Tease type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF 1?ORhC "MARK ONLY ONE ITFW 1. Mark an (X) in the box next to the item that (pest describes the reason the form is being completed. 2 Indicate the DBA A or Facility narne where the: tank is installed. 1. TANK DES RIV110N - COMPIZFE ALL T113MS - IC? UNKNOWN - So SP A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the birR ,,, (ex. i�D` ^189) I3, indicate the name of the company that manufactured the tank (ex. 1% lis SANK MFG,), C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank rapacity in gallons (ex, 25,000 or 10,000 ctc.). 11, TANK, C"C) I1: I ' A. 1. If :4iCJ"1OR VEHICLE It`UEL, check. box :1 and complete items B C. 2. if not MCYI'OR VEHICLE FOEL, cheek the appropriate box in section A and complete items B fly D. 13. Check the appropriate: box, C? Check the type of MOTOR VEHICLE FUEL (if box'1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the: C;.yA.S. . (Chemical Abstract Service number), if box 1 is NOT checked in A. M. TANK C ON . U(71;10 - MARK ONE rIUM ONLY IN IX)X A, i3, C & 1) 1. Check only one item in TYPE CBE" SYgfEKTANK MA TiRI L, INTERIOR R LINING and CORROSION iall6)'1'EC7170N. . If CJ'I"11ER, Taint in the space provided, IV. PIPING MORMMION 1. Circle A if above ground; circle U if underground; and circle troth if applicable. 2. If UNKNOWN, circle; or i€ d7'i'1 1 Ct, print in space provided. 3. Indicate the LEAK i3T,TECTIION systcra(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK i)InM 1C1 1, Indicate theEAK DE-X71.10N system(s) used to comply with the monitoring; requirements for the tank, 1.1i'fl J DA711H 1A 1' C.7SED - :4 ON 1YE AR (January, 1988 or 01/88). 2. Cl?At "'t:[3 QuAN-n'I'Y or IraAZ.AtI,I)OUS tii ,`TAMC II. remaining in the tank (inGallons). 3. WASTANK FII.,I..1,T) Wflli INE r i)XF IAL? ;heck ' Yes' or `NO'. APPLICANT UI;I' 1CaId AND DX111"1"111? FORM AS IN61CA117D, 'I'he state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739I 2121. The facility number must be the same as shown in fo "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefert the State Board to assign:: the tank number, please leave it blank. t r1' I 1. V-SPON.19rI3ILffy op "I az i Dew, AciPNcy n iAT iNsmicis =3 Fika 1' y °tom 1? I1 -y `1`iiit 8A^.e'Adw1.: tJIA WLlisA 8€III'R;a,g9.t'98f& AM—SP0..B :PAd'WL`H"R;�iR ARPs6.eWrm,n ..a.u.:Rv 'vzRaw::x uaumx zn aax eu.m zawsmco.�wan aam.sa: iii *13*(s) TO 111 OWIN I DDRI. a r 1'Ll W)VITiR RESOURCIINC iNr OLIX)ARD /C) smaFIgo. i I° R .SSI CINMR P.O. 'BOX 527 PARAMOUNI�,