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It i"1CUC 110NS FOR CC) . LIf IING FORM 'IV <br />L One FORM "Et" shall be completed for each tank for all NEW PFR I' S, PE RM r cnANcuis, Rumovms and/or any <br />other TANK IM1ORMXFION C 1 <br />2. This form should be completed by either the PERMrr APPLICYWr or the LOCAL AGENCY IJ I RGRz U TAN <br />INSP g <br />1 Please type or print clearly all requested information. <br />4. Use a. hard paint writing instrument, you are making 3 copies. <br />TOP OF FORNE *M.RK ONLY ONE ,3 <br />1 Mark an (X) in the box nest to the itenn that gest describes the "reason the form is being completed. <br />2 . ` .. Ih .' t name where the tank is installed. <br />J. 'YANK D SC RIVIIt } .. 'i. I li All, r113MS - IF UNKNOWN - SO SffCU1Yi <br />A, Indicate: owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. ABTY789). <br />EI. Indicate the; name of the company that manufactured the tank (ex. AC E5 T'ANK MFG.). <br />C. Indicate the year the tank was inst ed (ex. 198'7). <br />T). Indicate the tank capacity in gallons e . 25,000 or 10,000 ctc`)--' <br />1.1. TANK CON112f][N. <br />A. 1, 1f MOTOR VEHICLE, FUEL, check box 1 and complete items B & C. " <br />2. If not MOTOR VEHICLE LE FUL, check the appropriate box in section A, and complete items B &, L?. <br />B. Check the appropriate box, i <br />C. Check the type of MCI'I`OR VEHICE>l FUEL (if box 1 is checked in A). <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 i ox l is NOT checked in A. <br />Ill_ TANK CONS t1 ION - MARKC) Y112A ONLY CST BOX A, 11, C & D <br />1, Check only one item in TYPE OF SYSTEKTANK MATERIAL, INTERIOR LININGS and CORROSION PRO'll C.'i`IOM <br />2. If OTHER, R, print in the space provided. <br />IV. PIPING INFORMN17ON <br />1. Circle A of above ground; circle U if underground; and circle both if applicable. ' <br />2. If i1NlCaN"C.iWN, circles or if OTHER, print in space provided. <br />3, Indicate the LEAK DtItCTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK. DBIFA-11ON <br />1. Indicate the LEAK DE'113CTION system(s) used to comply with the monitoring requirements for the tanL <br />1. INFORM.A11ON ONTANK PERMANENITYCIXW.0 IN PIAC~"I-0 <br />1 KS11MA'11,I) SAI I -AST USED .. Mt)NTI /YFAII (January, 1988 or 01/88), <br />2. S111MA'TED C) )ANi'l't1'1* of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), <br />3. WAS TANK FILLED WITH C1Jl:'RT 111A'IERIAL`r Check 'Yes' or 'Nt)'. <br />APPLICANFMUST SIGN AND DATET1113 VORM AS IM)ICAIED. <br />I ,' IM UCII N FOR'11W, W, AG C iUN <br />The state tinder ed and storage tank identifickion number is composof the two digit county number, th three digit jurisdint%on , <br />number, the six digit facility number and the silt digit tarok number. The county and jurisdiction numbers are predetermined and , <br />can be obtained by calling the State Board (97.6)739-2421. The facility number must be the same as shown in form "A". The <br />tank number may be assigned y 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 />1"1` IS 11 -IE RESPONSIBUJIT OF T11E LOCAL AGE .I1 . "1" INSPE?C"E T(Hi EaAC.IIJI' 'M VE '1111? <br />ACCURACY OF 71 N1` 0N. 711E LOCAL AGENCY IS RESPONSIBLE FOR 11113 COMPlInION OI?'11IE <br />OLO(AL AGENCY USE ONLY' 'nO X AND IX) C FORWARDING ONE FORM ".A! ANIS A.SSOCVI'I ii <br />Ik)-Il"(s) TO 171II«C3 C"a ADDRESS. <br />C/o smy—aps. <br />DATA "P Cs CENnIR <br />P.O. BOX S27 <br />PARAMOUNT, <br />