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INt�]RUCITOld's FOR COMPLITONG *B'
<br /> til Nt;RAL INKIRLUK IllyiSu
<br /> t. One L'C)I<;l° "I3"shall be completed for each tank for all NEW PER S,PTIR F C;I GFa„s; REMOVAIS and/or any
<br /> pTANK
<br /> NUX.) IVINON CHANGE
<br /> 2, his should ted
<br /> by either the PE R TT PP CAMI`car the LOCAL AGEN(TY UNDERGROUNDTANK
<br /> Spey
<br /> 3, please type dr print clearly all requested information.
<br /> 4, Use a a<a d poinr writing instrument,yc.=.0 are making 3 copies.
<br /> TOP OF L=ORkC WARK ONLYt3NE rHIM"
<br /> I 'lark an t ) in the hox nexa tc? the b m tfh at best describes thereason the form is being completed.
<br /> 2. Indicata the MBA or Fadlitlyname,where the tanks installed.
<br /> 1. TANK I)Ii. ','RIIC1 ION.. C sell%I MJF xt.,I C"II;t S- 1Fr UNKNOWN-,'i(),'i$1?(HI
<br /> A. Indecme owners t,a..Y< 11) # - if thcro .s a tank number that isused by the yawner to identify the tank(ex.rylt70989).
<br /> II, indicate the came rat'ibc c napsny that a as<anuf'acturcd the tank (ex.AC ME:>'l'A"aFC'MFG,),
<br /> CIndicate ihe ycar 1hu lark-as n1 Lt`lcd .< 937)
<br /> 1). l.tit.icat ,its tank Ctpacity in ga.l,a.s(cx. ; ,x�;:or 1t),000 etc.).
<br /> IL TANK MN11IN'.I`
<br /> A. l, It ylrl art I illC°i_ I C I L, check ba x t =nd ccaanp=etc iterns Il�C.
<br /> d,. If no, MOTOR .E411C LE FUEL, check the aplacal bate box in section 1F and complete items B & Ii,
<br /> B. r the appropriate box.
<br /> C, Check t heof WOTOR V11IIC I I: FUEL 1.(if box 1 is checked in A).
<br /> 11 Print the.4h_crsical name of fee hazardous substan€e stored in the tank and the C.A.S. .(C hernicat Abstract Service
<br /> art b ,-) if box 1 is NOT d ch ckod its A.
<br /> IIF. TANK C4tvvS°I'RUC]ION -MARK CINE"rll,,M ON1,Y IN I oX N Ii,C
<br /> 1, Check wi; E nc'. tcnl En, t`pk` OPSYSTEATANK IMA"II°,IIf1I.., 'vTL',l IOR LINING and CORROSION I'EtOTF,£' OMC
<br /> 2. if t)'Fllf,l prae a in the space provided,
<br /> IV. PIPING INFORtANOON
<br /> L Circic A if above ground; circle pi if umtergrtaund; and circle both if app Iheable.
<br /> 2. It UNKNOWNcirdc, ur if (ski"111 IL,print ;n space provided,
<br /> Indicate, the LL&K I?1.a l: "I'1 system{s) used to comply ly with the monitoring requirement for the piping,
<br /> V. TANKLEAKI)MIX711ON
<br /> 1.. Indicate the LFAtb DI7T iC7]b'1)ti s sterss(c) used to cornply with the monitoring requirements for the tank.
<br /> VL INFORMATION TANK PER LANIU 1 . C:'LOSt9.1)IN PLACE
<br /> 1. F ea'l JM,1 rt, A IIS:I Rail"IISiIi)- 1CJI°,MI/Y AR (January, 19€18 or 01/88).
<br /> 1 I c-11Mrytl;11t Q ANI'I'I"i'of HA ,%R OUS SUBSTANCE'remaining in the tank (in Ciaticros).
<br /> x. WA i IANK FILLED'LED' ITT INNE R'I" °k YVI'E Ah? £:;heck'l'es'or'_NO'.
<br /> lit 4 A p Mlt,S'SIGN AND DA' l"L"I 'I?'FORM AS INDKWI130,
<br /> INgrRucirtold FOR111E LOCAL AGENCIES
<br /> The state underground storage tank identification number is composed of the ovo digit county number, the three digit jurisdiction
<br /> number,the six digit facility number and the six digit tank number, 'Ibe county and jurisdiction numbers are predetermined and
<br /> can be obtained by selling the State Board(916)139-2421. The facility number roust be the same as shown in form "A.". The
<br /> tank number may bel assagned by the local agency; however,this number must be numerical andcannot contain an alphabet. If
<br /> the khat agency prefer-the State Board to assign the tank number,please leave it blank.
<br /> 1'1S'flit?'IIF?I PONSIBII I' 0171111®LOCA C1I�C" 'I[t '1`1 5 1£"I S'[[FI3 FAC FF 1VF:RIF'Y IE
<br /> A "C`I RACY OF TIM I A"L'ICi14- 'ITIE LOCAL AGENCY IS RESPO Sftit 'MR*11111 COMPLEMON£?F1111;
<br /> '1,C(:Af.MANCY USE ONLY'INFORNIMION IMAND FOR FORWARDING ONE FORM W AND Ate' C;IM D
<br /> 1tORIv "F(s)'I°£ 11113 1F"()1.J.O' i ADDRE&S.
<br /> ,MVIT'OF CALIFORNIA
<br /> FS 1'A`M WNITR RE 7 t11.£.'I £CIMF"I OL BOARD
<br /> C/o S.W..L?1?P.S.
<br /> DATA PRCSCMMSING CIWIIIR
<br />
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