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WPM
<br /> ISS t RUIT "I OTNT.S FOR C:OMPIZ"1 NG VORM Glx
<br /> GENERAL€NS° Ut., ONS:
<br /> r:ne f,"O M `Wshall be completed for each-tank for all NEW PFRMWIN,P1 ;II I'I'C11ANGEN, ICI.IVIOVA and/or any
<br /> other TANK INFORMYV1.10N CIIANG&
<br /> 2,. This, forrn stat old be completed by either the.PFRMrr. 1'LS a °or the LOCAL AGE C" UNDE,RGROUNDTANK
<br /> , ],lease rt pc or priest clearly all requested information.
<br /> C
<br /> sea hard ;,int wr°(tiq instraan�enrrt,ys�u are aki copac
<br /> TOP OF FORM'M[ARK ONLY ONUE[lM
<br /> i. Mark tan I(X) in the box next to the item that best describes the reason the forret is 1)c,in g completed,
<br /> 1 Int icartc. the DIIA or Facility name where the tank is installed.
<br /> L 'I" K.D SCI I N)TS-COMPLUM All,MIMS-IF T NK'NO W -SO SPECIFY
<br /> A� Indicatc owners tank I «If there is a tank number that is used by the owner to identify the tank(ex.A 70789).
<br /> It, indicate the manse of the company that manufactured the tank(ex.ACMI_"s']AN MFG.).
<br /> C`,. Indicate the year the tank was installed (ex. 1987).
<br /> I7. Indicate; the tankk capacity in gallons(ex.2,5,(0f)or'10,000 etc.).
<br /> It. TANK C:C)Mi'ININ
<br /> , L If MOTOR VEMICIJ.�FUE"L, check box 2 and complete ftems 11& (I
<br /> 2. If not ?dC3'i'O Ii111CI.I';FUEL,check the appropriate box in section A and complete items IJ& D.
<br /> L. Check t0w appropriate box.
<br /> C Check°ries type of s3C)mfk VEHICLE I UE'L.(if box I is checked in A).
<br /> 11 Print c.i, chemical name of the hazardous substance stored in the tankandthe(.A,S: . (Charnical Abstract Service
<br /> numbcC), if box 1 is iL£IT checked in A,
<br /> tit. TANK CdONS"I I:M3'ION_MARK ONE FFEM ONLY IN BOX&I1,C:&13
<br /> I. t'l ck a=try c>rrc i�;et iso"I i I'll,C)I S SII vvl," `z �€ I 'II IC I<.thllslZ t�l2.I.t�i (s attd CORROSION i'12.UIEC.lION.
<br /> 1 If t":31IsER,print in the space provided.
<br /> IV., PIPING Il'd1' t( UVI'ION
<br /> 1, C;irele zrS.if atscx"erc�raaad;circle t3 if aszsdcr rounch and circle"both if applicable.
<br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided,
<br /> 1, Indicalu, the LEAK need to comply with the. rnonitorirag:rccluirement for the piping.
<br /> 1, Indicate the i,Ez% IJI"I" CFION systeen(s)used to comply with the nionnoring requirements for the tank.
<br /> 1, ES UMATED DiVrE I ASF USED-MO NVI-II/Y EAR(January, 2988 or 01/88).
<br /> 2, ESTIMATED QL;A"''I't'I 'cif IIA`,ZAILYIOUS SUBS"IA C E renaming in the tank(in Gallons).
<br /> 3. WAS'I ANK FILLED W11It INl.M'MI AI L"sRIAL`t (:;heck °Yes'or'Sq(.)'.
<br /> PPLIC' "I`MUS"I`SI(i AND i tM31111I TtORM AS I I(WIT7>>.
<br /> t SFRIFC.;1'ICJI OR 11111 L( I&L A E CII nS
<br /> `Ihe state underground storage tank identification number r 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 numbers are predetermined and t
<br /> carr,be obtained by calling the State Board(910)789-2421, The facility number must be the same as shown in form "A". The
<br /> tank miniber may be assigt'ed by the local agency; however,this number Hurst be numerical and cannot contain an alphabet. If
<br /> the Focal agency prefers the State Boardto assign the tank number,please'leave it blank,
<br /> I'I'is Frit,RPSPONSIBUXIT Ca t`L'M LOCAL AGSM-*111M NSPIX-PS'1T1E FA(T11 Y TO VERIFY".'III?
<br /> ACCURACY OF`1It°I FORM ION. ITIE LOCAL AGENCY C IS RUTS X)NSIBL E FORUM M(,'C3MPI MO OF111H
<br /> TDC AL 6 C Y USE ONLY'I IL ORSI ION BOX ANDFOR 17OR tSlkDING ONE MRM W AND ASSOCIATUD
<br /> FO -B-(s)TO 1311:.M11. WIN i ADDRUss.
<br /> 51WIT'OF CALIFORNIA
<br /> ISAROU* '.A 9K723'
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