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O 1 13ICA1, L III'RU('1' C) I;
<br />I. One IaORN '°II" shall be completed for each' tank for all NEW PE&MYPS,F,R I'1' C RANGE ASI, I°,IWOVAI and !or any
<br />otherTANK 17 ") A'I"7C) 1 C: CIS
<br />2. Thisforrm, should be completed by either the; P . I" APPL1C"A 1' or the; I,,() AI.. AG1!NC'11 iiNl)IiI2CIRC)L7ND TATS'
<br />Please r r print clearly all requested information,
<br />4, Use a hard €m writing hist:run o€tt, you ark. a ak"snf; ; c antes.. ,
<br />'1UP OF Ia`ORM,- 'Wls C ON1,Y C) II1 I' 7t "
<br />L. "tdark ars (X) in the po% Itext to the item that best describes the reason the form is being completed.
<br />2. Indiaaw, the -)I3 of Facility came where the tank is installed.
<br />I. TANK I)I^.SCRIP IO - COMPIHIM ,ALL, n'FMS - IF UNKNOWN - So SPECIFY
<br />A. Indicate owners tank IIS # - if there is a tank number that is used by the owner to identify the tank (ex. A1370789)._
<br />I3, Indicate the: nza€aye of the company that manufactured the tank (ex. ACME "i'ANK MI'(1).
<br />G Indicate the year the tank was installed (ex. 1987).
<br />D, Indicates the tank capacity in gallons (ex. 25,000 <>r 10,000 etc).
<br />IL 'TANK C O IU I
<br />A, 1. If MO f'OR VEHICLE E'[. EL, check box 1 and complete items 13 Cl
<br />2. If not MOTOR VE'LITCLE, E'UIT, check the appropriate box in section A and complete items B & Da
<br />13. Check ! ;c: appropriate box. Y
<br />C. Check e; type of {)'rOR Vi FIIC FUEL (if box I is checked in A).r
<br />I), Print the chemical name of the, hazardous substance stored in alae tank and the C:.A.S. . (Chemical Abstract Service
<br />nu€a b rl, if box 2. is NOT checked in A.
<br />111, TANK ) g;1'7t I If:"I`I£) f - MARK ONE I`I :ONLY IN BOX A, It, C & i
<br />1. C:he<k ;nly one; item in TYPE Of' SYS`FEM, "TANNIC iviA"I` " IAL, INTrER OR, LINING and CORROSION I ROTE3fTIO ,
<br />2. If C3 i HI'vit, print in the spaen provided.
<br />IV, PIPING INIURMNPION
<br />1, C.°ircle F`k if above ground; circle U if underground; and circle hotly it applicable.
<br />2. If UNKNOWN, , circle; or if 0`111ER, print in space provided.
<br />3, I€adicate the LEAK I 111"C' ION syste€ta(s) need to comply i*iih the monitoring requirement for the piping
<br />V. 'TANK L E.A-K 1. x at I'IO
<br />I, ,acct Lam. A."i'l:,L"'' ON system(s) used to comply with the monitoring requirements for the tank.
<br />1, I-Asr usi:'I) m uNmij"� A (January, 1988 or 01/88).
<br />2. E:> "I l .r `I'I 1i CSI A "i'I"I t' of IIA I2I:i()l 4I 134IANC E renuuni€at in the tank (in Gallons).
<br />3. AS I' NK FILLIJ) W11IIf I:viEi)'1''kiATE S1iL? Check "Yes" or'NO%
<br />A1'IMHOA 17 UI;r SIGN AND 1: NIB "I II3 MRM S I KW II1 ,
<br />Ii* I'1L CEION � .'t�,1 I WCAL AG]ENCIUS
<br />The state underground sva ragc, tank identification number is Composed of the two dight county number, the three crit jurisdiction
<br />number, :ha digit facility number and the six digit tank number, °fico county and jurisdiction numbers are predetermined and
<br />be a rtai yeti by saflirar the State Board (916)739-2,421. 'I`he facility nuraaher must be the same as shown in form "A". The
<br />tank nurnbc.:,_aI be assigned by the Local agency -,however, this nuttib r must be name:rical and cannot contain an alphabet. If
<br />the; local agcncy prefers the State Board to assign the tank number, please fe;ave it blank.
<br />TI' I:3'1111? 1 i -,'SP )NNlB IX.I' OF 17111 LOCAL AGU CY 3`1L ''NhPIX1 'V%'11111 1ACT T1'Y `ft) SII RIi Illi?
<br />ACC I l . TY C)7' `nfl.' INFORMA110N. ITIF LOCAL AGENCY Y Ila 42NSI'ONSIBLE IaC)1211W COMPUNION OF111P.
<br />"I,C) . A(IIINCY USE, O IzY°" RMN)IC7hi BOX AND FOR FORWARDING OOP. R)RM W AND RISS) *ED
<br />FORM �I3"(r) `I I 1 )I,I.0WTNG ADD, ILIA.
<br />17NIT 01= CALIFORNIA
<br />,. "T ' '11,WA31, IC. CaOMIROL BOARD
<br />P.OWX I ') 52
<br />y .r
<br />Ask JL
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