|
151' UC„ IIONS ILII CECT PI q INC"a OMIr
<br />GE' RAI, I Via` RUC1 ONS
<br />1, One FORM "I3" shall be completed for each tank for all NEW PERM IN, PI Immo CHANGES, RFMOVAIS and/or any
<br />other TANK INFORMN110N (31ANG11.
<br />2 'Ibis form should be completed by either the PFRmrr APPLICAN17or the LOCAL A(.3N . Y UNDERGROUNDTANK
<br />INSP M " ia32
<br />3. Please type or `print clearly all requested information.
<br />4. Use a'hard point writing instrument, you are making 3 copies.
<br />TCIp OF IX)RM. -MARK CIIdLY ONE rnige
<br />L Mark an (X) in
<br />the box next to the item that best describes the reason the form is being completed,
<br />2. Indicate the DBA or Facility name where the tank is installed.
<br />I. TANK I'3It RIV110N -'co mn.I? ' M ALL rnimis _ II -a uNKNOwN - SO zSTuKlI Y
<br />A Indicate owners tank Il} # - If there is a tank number that is used by the owner to identify the tank (ex. AI370789).
<br />13. Indicate the name of the company that Manufactured the tank (ex. ACMI—TANK MFG),
<br />C. Indicate the year the tank was installed (ex. 19$7).
<br />I). Indicate the, tank capacity in gallons (ex. ,(M or 10, etc.),
<br />11. " TANK O( 3,WI S
<br />A. 1. If MOTOR VEHICLE FUEL, check box 1 and complete items 1:3 & C.
<br />2, If not MOTOR VEHICLE FUEL, L, check the appropriate box in section A and complete items i3 & D.
<br />B. Check the appropriate box.
<br />C. Check the type of MC31'01C VEHICLE FUEL (if box 1,is checked in A).
<br />D, Print the chemical name of the hazardous substance stored in the tank and the t;,r1,.S. . (Chemical Abstract Service
<br />number), if box I is liar checked in A.
<br />Ili. TANK coN91'ICUC:11ON - MARK ONE rITM ONLY IN BOX A, I3, C & IF
<br />1. Check only one item in TYPE OF SYSTEM, TANK MA'T'E' IAL, IiiIEMIOR LINING and CORROSION I'IPO EC71,1 ?N.
<br />1 If OTHER, print in the space provided.
<br />PIP . G INM )VI'IO
<br />1. Circle A. if above ground; circle U if underground; and circle both if applicable.
<br />2. If L N NU N, circle, or if OTI IEE, print in space provided,
<br />3. Indicate the i.pa K Dh'13(110N system(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK 11DF[TTCI'ION
<br />]. Indicate the LEAK DL,-]'EE.'I'ION system(s) used to comply with the monitoring requirements for the tank.
<br />VI. INIORlLits 110N ON TANK PERMANFNIIY CLOSED I: I' C I3
<br />1. F STIMA:rl:II DiVIT LAST USED - M01N''I ii/Y I:AR (January, '1988 or 01/ ).
<br />2. ESTIM/0'I'D QUANT11y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br />3. WAS T ANK FILLED '4'trni IN KI' MATERIAL? Check 'Yes' car '_NO'.
<br />APPI,J(7%NF musr SIGN AND DN -1 ? -I-HE FORM AS R:M70, ,
<br />IPI U(a10N FOR1111I LOCAL AGENCIES
<br />'Floc state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction
<br />number, the six digit facility number and the six digit tank number. The county and jurisdiction number-, are predetermined and
<br />can be obtained b1= calling the State Board (916)739-2421. 1'he facility number must he the sante as shown in form W. The
<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 />II' IS TIIE tESPO S IIII: Y 01"11W IOCAL AC31 C Y I ,I, IPI P .i',S'I IE I?ACII, . 'F0 VE'RII nIE
<br />ACCURACY OF 311E I Ik) 7.10. '171E 1,()(:AL A I?PIL Y IS RESPONSIBI,Ji ISR *11113 COMP11nION 0171TIE
<br />'IDCAL AGENCY USF ONLY"INFORMATION BOX AND IK)I2 FORWARDING6NE FORM W AND ASS ly-D
<br />X " "(s) 'I O 11111 17011A)G AIT
<br />,5171VII! OF CALIFORNIA
<br />SI'°N NI AS UR(It WIzOL BOARDC/o smaaps,
<br />`
<br />DATA PRO(-M&SING CEWER
<br />PD, BOX 527
<br />P OUNI', CA 90723
<br />
|