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INSI° UC71'ION S L ) C°Cl Pi,191ING Efew , A
<br /> 1 One FORM"li"shall be completed for each tank for all NM P 117,PERWF CII A GIs S, RFMOVALS and/or any
<br /> other'I I K INFORM `ION MIANGFI,
<br /> 1 This form s €ukll be c;tmpicted by all her the FICRmn' PPI IN-p or the ,O(AL £lEN(Y J 12131$CsRO `I=I I
<br /> I S , "P
<br /> 3. Please type or print clearly gall requested information,
<br /> .:C. Usea, h.acd paint str ingl instrurnr w,you are making 3 copies.
<br /> 'MP P III¢FORM,WARK ONLY,Matta,I I laky
<br /> 1, Awk<an +fX) in ,he box?next to the item that best describes the reason the form is being completed,
<br /> 2. Tndicatc, .E. .a€1S or 1'adl,ty name.where the tank is installed.
<br /> 1. TANK DAIS.Rl.lyt'IO -MMP] M ALI,111 fIAS -It?UNKNOWN tI SPI-71C IF
<br /> A, Indlicaae o ,.:er arr 111 y - Il there; is a tank number that is used by the o ner t€> identify the tank(ex,rRII7078€;).
<br /> I3, lr,,rr,<t h1C nai,_ 01,t..a campsanv that manufactured the task(ex. ACM1,1 1:"t1N MFG,),
<br /> C. f llik"ate flhe wca, .h, _.„k M inst0. cd (ea. 1987).
<br /> D. at lira. ,he wnk ravay f',gallons(cx.Z5,`KKI or l0,000 etc.),
<br /> II. TANK C I'VIN'i
<br /> A. 1, li 1ta,s c t '`r tliC i_I 1 UI i,, check box 1 and cctrrptete itetrts 11& C",
<br /> ? trot .. J`=(.)lc {'I lin l l_;la'c_;r 1,,check the a,prcag,iate Crox in section l? and complete items It& Il.
<br /> 11. r`hc k tars sr, rr t ate t oa.
<br /> C. t hcck the type c t '4aa tyO 4I_ 11C t E,I'l t i (h'box i is checked in A).
<br /> Ira, Print the _hcv,muca.=,ame of le lard"oas substance stored, in the tank andthe C A.S. , (Chemical Abstract Service
<br /> aurnbe if t ox r is N€.1T c her ked in A,
<br /> TIL TANK C tsWI"1kI=C"1"ON-MARK ONEG'EM ONLY IN BO 1I,C& 7
<br /> I. Chd ck n,0.y one l,tri in"4 YPEi.CCI SYSTEM''E"cINK MATERIAL, INTERIOR LINING and CORROSION PRO`I Fi,C'rIO .
<br /> 2. If 01'111 fC, prig in the,spacc provided,
<br /> IV. PIPING INFORMNFION
<br /> 1, Circle A if ahctvi- around; circle bl if underground; and circle both if alpiicable.
<br /> 2, 1¢ k NKK atV N,d ar if OTlIt EI,print in space provided,
<br /> 3. indicate .h used to compiy with the monitoring requirement for the piping.
<br /> V. TANK IJe%X DKITI(MON
<br /> 1. Indicate the LEAK flETFIC ION sysim (s) used to corxtpfy with the monitoring requirements for the tank.
<br /> V1. INFORM.YMON ON TANK PERMANEMMY CLOST.D IN PIAS?
<br /> 1. 1i5111riIs'IED DAXF1 IASL'USED-molk`I'ti/yM (January,1988 or 01/88).
<br /> 2. FSTI'k/VIVID OUANrlTY of HAZARDOUS SUBSTANCE remaining;in the tank(in Gallons).
<br /> 3. AS TA. N C I.31 f IT) WITH ENERT M VI`ERIr L? t:;Eac ck'Yes'or'NO'.
<br /> APPI1CANW MU,`I'SICIN1k=: D 33 '1"If 111F,FORM AS INDICAFED,
<br /> 1517Ib,ilClNO 1 111 1111'LOGAl.1LGENC>ILxai
<br /> The state underground stowage tank identification number is composed of the two digit county number,the three digit jurisdiction
<br /> number,the sir digit facility number and the six di-it tank number, The county and jurisdiction numbers are predetermined and
<br /> can,be obtained by calling the state Board(916)739-2421. `1`he facility number must be the same as shown in forma"A , 'ne
<br /> tank number may be assigned by 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 /> I I'IS nUr I2L 51'C)N5II3Li 11 I:IFt'LIFif IOC: CiF{ 1F I`l ,[S`I1IR IrAM Y TO VE'RIF 111E
<br /> AUNURA(,'Y C F 11T , 1C1'Clll "li£ltsl. 711F L,CF(:AL AOEN(.Y IS ICF,PONS11?F,1 F '11111 t't3t l'I;Is"I O OF 111I1
<br /> 'I Cat .. GE C` USE,ONLY'L,' 'Il'd''OR 11O AND FOR FORWARDING ONE FORM'A' IBJ SS (-71)V 7D
<br /> FORM-I-(s)` 0''1IE 1701LOWING G KIDDIE S_
<br /> 1"la°I`ll tilt(MIFORNIA
<br /> C/o S. min P.S.
<br /> Il a'I'A 1p1s.O(liSSI G NFNMR
<br /> R
<br /> P 4]e BOX 527
<br /> ImAli.tl v C)LTNF, `.ri 90723
<br />
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