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S' LIC"1 CF S FOR K°Ci . I..., G 11X)RM 1ROff"
<br /> GENERAL I S RUC EE S
<br /> L One FOR "IT"shalt be completed for each tank for all NFW PER ,PERM171'CFIANGE,S, REMOVALS and/or any
<br /> other TA ) 11ON CHANGE
<br /> E?
<br /> 2, This goy form should be completed by either the PE r PLICAN'or the ' I.,ADEN., U 3TCGRO D"I N
<br /> INSI'F a.yy-Ld Ate.
<br /> 3, Please type or print clearly all requested information,
<br /> 47se a hard point writing instrument,you are making 3 copies.
<br /> T011 0,17 FORM.OMARK ONLY ONE r11BV
<br /> 1,, Mark an (h) in the box next to the item that hest describes the reason the forn is being completed:
<br /> 2. Indicate the DBA or facility name where the;tank is installed.
<br /> I, TAN LSI-SCRIVI O -COMP11qr,AIS rnws-IF uNKNowN-SCJ SP1?CiFY
<br /> A, Indicate owners tank 11) #-If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> F3, Indicate the name"of the company that manufactured the tank(ex.ACME:3'I'AN Iv F'G,)
<br /> C. indicate the year the tank was installed(ex. 1987)-
<br /> 1), Indicate the tank capacity in gallons(ex,25,(M or 10,000 etc.),
<br /> H. TANK C.OfqTENIS
<br /> _.
<br /> A. 1.. If MC)`EOR VFIIICI..,E FUEL,check box 1 and complete items B& C.
<br /> 2, If not MOTOR VI IICI,E;FUEL,check the appropriate box in section A,and complete items 11& D.
<br /> B. Check the appropriate box.
<br /> C:, Check the type of MOTOR VEHICLE,FUEL(ifbox1 is checked in A).
<br /> I3. Print the chemical dame of the hazardous substance stored in the tank and the C A,S. . (Chemical-Abstract Service
<br /> number),if box I is NOT checked in A.
<br /> "III, 'JANK C ONO 3 O -MARK ONE 1711W ONLY IN BOX A,I3,C:&I3
<br /> I. Check only one item in TYPE OF SYSTEM,`1'ANK ItSNFE'RIAL, INTEIRIOR LINING and CORROSION PROTE(C 1100,
<br /> 2, If OTHER,print in the space provided,
<br /> IV. PIPING I R A`1'Od
<br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle,or if 0'17HE R,print in space provided,
<br /> :1. Indicate the LF,AK:D7!,T;C'I'IO system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TAMC L?.A D1"I71?,C 1`10
<br /> 1, Indicate the LEAK DETE(;IION system(s) used to complywith the monitoring requirements for the tank.
<br /> VI: IWORMATION ONrANK PER I I Y C- D IN PlAcli
<br /> I. ElfflMA7TI)I'NI'E I.,,AS'T`ISM)- C2. `II/YEAE2 (January,19 88 or 01/88).
<br /> 2: ISM S A"E I>t> I.`AN TE"1:'Y of IIA '6 I)O S SLl33ST ANCE rernaming in the tank(in Gallons).
<br /> 3.', WAS`t< NK FILLED WFI'll INERT \TE✓RIA1.1 Check's"es'or'NO'.
<br /> API I (' S'E SIG AND D/V17II 11IR FORM AS I SIC NI`; D,
<br /> JNS TJC:E10N I IS"1'I1H LOCAL AGENCI I*S
<br /> The state underground storage tank identification number is composed of the two digit county:number;the three digit jurisdiction
<br /> number, the six d°sgxt facility number and the six digit tank numben The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2321. 'I"he facility number must be the same as shown in form "A"; The:
<br /> tank nirrnber may be assigned by the local agency, however, this number must be numerical and cannot contain analphabet. if
<br /> the lo€8ft agency prefers the State hoard to assign the tank number,please leaves it blank,
<br /> IHI
<br /> ITIS THE E S NSIBUXI'Y OF TIIE WCAL A(JENC Y'n INP INSPI N`1'1111 FAC 'Y'1'C}VERIFY THE
<br /> ACCURACTY OF ITIS INF `PION. 'ITIS LOCAL A.ACIYINC 'IS IIINPONSIIII*I's FOR 11111 O PLEA ON OF 1111?
<br /> "LO(Y&L AGENCY USF ONLY'INFORMATION BOX AN[)FOR FORWARDING DING€3 :i-FORM'A'ANDAsSOCINno
<br /> FORM Oil"(s)TO 11111 MLLOWING ADDR17-SS,
<br /> STKfE WNITIR RaSOURCES COWROL BOARD
<br /> C/o S. .,
<br /> P.O� BOX 527
<br /> PARAMOUNF,CA 90723
<br />
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