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<br /> !NFIRUCTIONS ly-)R COMPIZ17NG 11YORM
<br /> GFNERAL 1NSFRTJC,T10NS-
<br /> 1. One FOWN-113'shall be completed for each tank for all Nl,,.W PURMIN,PI.,.RMH'C'T1ANGW. S,
<br /> other 1ANK IWORMN110IN C11ANGP-
<br /> 2. This form sl.auld be CoTnpielcd by c;01cr the PER.MrrAPPI.ICANT or the [A)CALAGENCY
<br /> TNSPFXM" R.
<br /> 3. P!,-,ase tyr: f-,r print clearly all requcsted information,
<br /> 4, Use a haro po�nt writing nlstnumQr,., ou am- niakmg 3 op
<br /> es.
<br /> "(.Al MM. -MkK oNtAr 0o:ibum-
<br /> 1, Mark gn (,K)in the box next to the item that best describes the reason the fonn is being completed,,
<br /> 2. lrwliiiat�Ike,IWA_br Facility name where the tank is mstMled,
<br /> T.JiNAK AI-J,MWS-IF UNKNOWN-SO WMW-i
<br /> A. owners tank 1D # -If there is a tank number that is used by the owner to identify the tank (ex..A]370789).
<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. 1987),
<br /> D. Indicate the tank capacity in ballon(ek,25,(W, or 101(0 etc,).
<br /> 11. TANK COM11WIN
<br /> I and complete items B &C.
<br /> A. 1. If IM07.011 VEHICLE FUEL..check box
<br /> 2. If not '-A,)T0R VIMICLE FUEL,check the appropriate box in section A and complete items 13 & 1).
<br /> B. Check-,the appropriate box,
<br /> C. Check the type of.%mul-OR VEHICLE,FUEL(if box 1 is checked in A
<br /> D. Prin! the chemical name of the hazardous substance stored in the tank and the C.A.S-#. (Chemical Ahstract 53q-vice,
<br /> nui, if box I is NOT checked in A.
<br /> .,,,N RUMON-MARK ONE rIFM ONLY IN BOX A, R C&D
<br /> 1. -'heck only one item in't'4 OFSYSTEM.TANK MATERD-d.,INTERIOR LINING and CORROSION IIROTfCIION.
<br /> 2. If(YIIIEP,print in the space prcwided.
<br /> !NK)RMJVIION
<br /> 1. Circle A if above ground; circle U if underground:and circle both if applicable.
<br /> 2. If UNKNOWN,,circle; or if 0`111 R,print in space provided.
<br /> 3. Indicate the LEAK DFT1lcrt0N system(s)used to comply with the monitoring requirement for the piping.
<br /> -AK DITM-1.10N
<br /> 1. J; 0
<br /> Indicate the LEAK D141 ..(TIOIN system(s)used t comply with the monitoring requirements for the tank_
<br /> V1. INTIORMMON ON TANK PERMANE3MMY Ci OM)IN PIAM
<br /> 1. F�SMMAT!D DNM LASTUSED-!,%ofONTlI/YEAR(January, 1988 or 01/88).
<br /> 2. 13,911MA:""D QUANT11Y of IIA/ARDOUS SUBSTANCF remaining in the tank(in Gallons).
<br /> 3.7 WAST`. VILLED wriii INTiRT N—MTERIAL?Check'Yes'or'NO'.
<br /> APPIJ(',A.';F MUSTI'ST'�,4 AND DATE III;," AiI iNl'[k'Al1D.
<br /> K'-HE J.,O(AL AGENCIES
<br /> state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction
<br /> slier,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> zan be obtained by calling the State Board (916)739-2421. The facility number must be the same 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 /> local agency prc(�, ilte State Board to assign the tank number, T. leave it blank.
<br /> �iFIXI'Y 01711M IXWW.AGENCY 71IAT VO WRIFY'ITIF,
<br /> IORMA`110N. MW STOMP
<br /> ' IA ��
<br /> N 'INFORMK D )CIA-
<br /> LOWING ADDRE M.
<br /> a. INCE CTWITR
<br />
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