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<br />I I I DOI SFc (XAMI1,11,1af YIX)R Ls-
<br />C:Sl;i -1s al, t 4,1�17RIX.I fC2` h'%kS:
<br />1, Garr', 'a- is >ha"H be completed for each tank for all NEW PF-RMn-S, PF rl' (11ANGIN, ?. 4;t and/or ;any
<br />,ther F NICNFORMNtIO CIIANGR
<br />fsi la ,.:, should irc :.<.r:a E ?e.d r y csither° the I19i1 "' 11` i I I" or the i C)C 1iI r C31:? IC LTI I i tCCKCiIJ iI "I NK
<br />INSI I f l'd' IC.
<br />Pleas,, tyt
<br />fte or pr"nt a ,,arty al; requested infcanna,tion,
<br />I_ [ sc,, a lvard toomt wratrt L instr€arrant, you at(,,, m ekirig 3 ,c., hies.
<br />I. Mark .;ra (X) in the fever next to the item that lest describes the reason the form is being completed,
<br />2, 1Indicate the DBA.or Facility ramie where the ilmis- is itastalled.
<br />I. 't°s NK 12I SCRI1111 I _ XX)M 'I.I UE ALL NI S - IF UNKNOWN « SO SPECH
<br />A, Indica-, ....*vners tank Il? If there is a tank number that., is insect by the ovrner to identify the tank (ex. B70789),
<br />II. Indic ate ::he narnF~ of the company trial manufacture l the t;a€ik (ex. ACME 'FANK MFGC ),
<br />C, Indicate the year the tank was installed (ex. '1987),
<br />D, Indicate the tank capacity in gallons (ex. 25,000 or 20#)0 etc.).
<br />IC. TANK (X)N1 ,N`
<br />A, I. If MOTOR VEHICLF, FUEL, check box 1 and complete hems Il & C.
<br />2. Ifs not g Cyl'OR V1111CLE" FUld- rheck the; appropriate box in section A and complete items 11 & D.
<br />C. Check tlac type of ylO'1'O y'I,I;ll(''1,l. :1 C)I'I, (i box .I is checked in r1).
<br />I ), Print the ch 'inicaal name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service
<br />n xtrte>a r), if box 1 is , . 'y checked rd in A.
<br />111. TANK C ON,13 RUC - M,,VRK, ONE TIUM ONLYBOX , B, C
<br />1, Check crawly one item inTYPE OF SYl li;"sK "t"ANK MA"t'EIRIAL, IN11:31UOR I,11NING and (.7OR12C SOON PRO'I'EC.110N.
<br />2, If OTHER, print in the spaceprovided,
<br />IV. rll"ASCIINI )IC ft"I'1411
<br />L C;ircler, A if above. gr€as.nd€ circle. U if under ronnel; and circle both if applicable. ,
<br />If I. NKN WN, ca��red.. € r if OTHER, lt"R, print in spam: provided.
<br />5.. Indicate the LEAK 1)11-11 r,C"I 0N' sysh n(s) used to cornply with the monitoring requirement for rise: piping,
<br />sf'IANK IXAK C I Is 111,71"IC 1
<br />1, lead€c<am the LEAK DE-1 ',,C1"ION s}stcrs(s) used to comply with the monitoring requirements for the tank,
<br />VL IN17ORMJVIION ONTANK I ERNIAN `L,Y CLOSET) E IAC7
<br />1. E,,yFI7,lA'I'E'D 11ATI: LAST USED M- M: 7,11/Y AR (January, 1.988 or 01/88):
<br />ES
<br />11, i I QUA > lrl of II��ZSI<IL1U S SUBS'y��N I" remaining in tine tank (i Gallons).
<br />a� "ASTANKIll,la=:; WITH 1',l1Kx MA'1 IZIAL7 Check Yes' or 'NO'.
<br />If'11£_ nTr mrsr SIGN
<br />AND DX11,z I IEFOR S INI(IM1
<br />INSI'R1JCll0FOR 1r11, LOCAL i ENCS
<br />The state aander`uro anal storage tank identification number is composed of the two digit county number, the three digit jurisdiction
<br />number, the six digit facility numbers and the six digit tank number.The county and jurisdiction numbers are predetermined and
<br />cast dem obtairied las cailinl, the State Board (916)739-2421, The facility number must be the same as shown in form 'A". `phe
<br />t snk nu at,c € n"al be assigned by tlhc h)c al Qag ncy, ltxawevcrY this number must be numerical and cannot contain an alphabet, If
<br />the iocaa agency pre fc ts, the ,ure Board trs assign itte tank number, pleas: leave it blank.
<br />r I IS TUE RFS','ay SlBlI.I'l'Y Call '.111 LOCAL AGEN(TY111AT I SI*I?C;3 `t :l AC11 `1' "'CI VERIFY11111
<br />ya .0 t:.,llAC'Y CSI° THE ISlls<111 IA 170 '"I`I ll tC ai, CSIa.CV(�S ifs Ci I'CD Sii3i li I 'i Lit? C:C)�91�IPi iICI 31� *i iiiA
<br />I ,a IC aP AGE.1`4 USE" < ONLY" INFORMA17ON BOX AND FOR ttORWA DING ONE ICOR "A' AND S` C,IXF1-0
<br />17ORM -B-(s) 110 THE"' FOLLOWING ADDR17-R&
<br />S 1. `JV OF CALIFORNIA
<br />OURCII CONTROL `IE !II I
<br />P.O.C/o smxulps.
<br />IIOX 577
<br />PARAMO.J €:° CCA 90M-
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