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II S I I.1C"I O S FOR C OMP1, 71'ING : "F
<br /> 1. One FORM"IV shall be completed for each tank for all NFW ' t ',%PIs I°CHANGE-S, 1IIiMOVAI and/"or any
<br /> otherTANK IM70RMNIION(MANOR
<br /> 2. This form sh€add be complete,-'by either the nmmrr APPLICANr or the LOCAL AGENCY U ERGiRO )TAN
<br /> I SI' I OR
<br /> 3, Please type or print:clearly all requested information.
<br /> 4. Use a hard point o-icing instrument,you are making-1cIopies.
<br /> OF FORM.WARKONLY ONE Ft' s"
<br /> 1, Mark an(:X) in the box next tothe item that fest describes the reason tlic form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed,
<br /> 1. 'rAN D1?SC RIVI TON--(>C) 1'I I ,,I'llI I S-l =Cly OWN-SC)S1"EC 1
<br /> AIndicate owners tank 11) # -If nhetire is is tank number that is used by the owner to identify tltu tank(cx.AB70789).
<br /> 13. Indicate the name of hire;company that manufactured the tank(ex,AC"4TI'TANK MF6.).'
<br /> C. Indicate the year the tankwas ins a,led (ex, 1987),
<br /> D. Indicate the tank capacity in gallorei{ex. 25,000,or 10,0)etc.).
<br /> A. 7. If 1Ts401't)P V EMICL,E; FUEL,check box T and complete items II& C,
<br /> 1 If not MOTOR V1111CLE FULL, check the appropriate box in section A and complete items B &:i7.
<br /> B. Check the:appropriate box.
<br /> C. Check the type of NMOT0R V17II1Ci.IS f°UEL(if box 1 is checked in A).
<br /> I). Print the chemical name of the hazardous substance stored in the tank and the C:.r1.S. .(Chemical abstract Service
<br /> number),it box 1 is NOT checked in A.
<br /> II1» 'TANK CObl l°ICI:IM ION-MARK C) 'LA rI Iglu ONLY IN BOX N II,C<,;&I
<br /> 1. Check only one item m"f`YP C)F ISY,°=`pE ,"1':NK 4TAI'ERIAI.,, INFERIOR LINING and CORROSION I'ROTFC I"ON,
<br /> 2. If CST HE k,print in the space provided.
<br /> IV. PIPING, INMRMAI°IC)T
<br /> 1. Circle A.if above grorumt circle CI if underground;and circle both if applicable.
<br /> 2. If Li'IL£°vtd ' catch; or of OUTER,print in space provided.
<br /> 3. Indicate the LEAK Ir I'IM ION ystent(s) used to complg vith the monitoring requirement for the piping.
<br /> V. TANK LMK DITITC711ON
<br /> 1.. Indicate the LEAK DE EMION systems) used to comply with the monitetring requirements for the tank.
<br /> VI. INMRMAMON ON TANK PERM WO 0-OSED IN P C 17
<br /> 1. FIS I'IMAT"E 3 A'11E T.AST USED- N£HJ'? l-. TAR(January,1�or 01/88).
<br /> 2. L S`3'IMzVrI 1)(DUAN` H-Y of HAZATS.I O S SUBS"IANCE remaining in the tarok (in Gallons),
<br /> 3. ,\S'.1,AN FILLED WI 1`11 INN RT MAT ERIAL,:` Check'Yes' or'NO'.
<br /> APP11(y,mr MUST SIGN AND,DKIEI'i ll?IURM )IC FED.
<br /> INSTMUMION FOR17111OC:tti,AGENCIES
<br /> I.S
<br /> '17he state underground storage tank identification number is composed of the wo digit county number, the threedigit jurisdiction
<br /> number,the six digit facility number and.the six digit tank number, The counter and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (910)739-2421.. `:E`he Facility number must be the same as shown in form "A". 'I he
<br /> tank number may be assiTnaed by the local agency-, however,this number must be nurnerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> TI'ISITIL RESPONSIBUXIT OF TH E LOCAL AGFNC'Y'I'II I'NSI?EM ME I' CII `M VERIFY 71 11-1
<br /> C C OF TIM'IIT() " .A.11C3 . `PITT?WCAL A0FNC Y IS RESPONS11.11.13 FOR.'1 111 COMPI ION OF 1111?
<br /> "LOCA).AGENCY USE ONLY"INFORMN]ION BOX AND ItOR fl11O DING ONE FORM WAND AS" M7D
<br /> 1 -W(s)TO 111E RMLOWING ADDRESS.
<br /> SEK17H OF CALIFORNIA
<br /> C/o e u F,&
<br /> XJA PROCESSING . ° TR
<br /> P.OG BOX 527
<br />
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