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001
<br />611 "WIRWNRIN
<br />GFNEMLAL INS17RUC71IONS..
<br />One FORST "B" shall be completed For each tank for all NEW PERmrfs, € UIRMI ' CHAN ES, EMOVA 4 and/or any
<br />other TANK IN]FORMA110N CHANGE.
<br />2. `11is lc.wn, should be completed by either the PERMrr APPU(ANI'or the LOCAL AGENOY UEIRGROUN TANK
<br />WSPJ 3T) A
<br />t ,� please type or print clearly all requested inforralation.
<br />4. Use PxaraJ,p ni.w tiszi instrument, you are making 3 copies.,,
<br />'IT)P OF FORM. 'MA.RK ONLY ONE ITEM'
<br />r, izrk a:t (X) in the sox ne t to the item that best describes the reason the form is being completed.
<br />2. Indicaic thal?IIA or Facility nante where the tank is installed.
<br />L< 'YANK DFSC:ICII"fl a -N '- r ftAPti'LEUE All, iT ? S - Us UNKNOWN a- So) SPEUIry
<br />A, Indicate owners tank ii) # - if there is a tank number that is used by the owner to identify the tank (ex. AB70789).
<br />13, Indicate the mane of the companythat manufactured the tank (ex. ACMFI "SANK iMY`0.).
<br />C, Indicate the year the tank was installed (€;x. 1987),
<br />D. lndi tate the tank capacity in gallons (ex. 25,000 or 10,E etc.),
<br />11. 'TANK Cuf)NJE I
<br />A, 1, If MO I'OR V IiIC,i I FUFL, cheep box :I and complete items 13 & C,
<br />2. I; not MOTOR V[1IICLE 1EC.'EL, check the appropriate box in section A and complete items B c& D. _-
<br />13. Cheek tl;c appropriate box.
<br />C. Check the tyke, of MOTOR VEHICLE FUF'L (if box] is checked is A),
<br />L), Print the chemical name of the ba�ardous substance stored in [lie tank and the C,ft.S.#, (Chemical ?abstract Service
<br />number), if box 1. is NOT checked in A,
<br />Ill. 'J'AN WN! LX -7110N _ MARK ONE rtliM ONLY IN BOX A, 11, C; & I)
<br />1. Check oTAy one itent in TYPE OF "Y5l'E , ' 'AN1{ MATI,,RIAL, INT RIOR. LINING atter CORROSION PROTFIrnoN.
<br />2 If 't"Ifl:a print in the space provided.
<br />IVy PJJ`LNG I FORM 11
<br />I.
<br />Circle A if above ground; circle Ll if underground: and circlee both if applictablc.
<br />2. If UNKNOWN, , circle: or if C)i'dlER, print in space provided,
<br />3, bwicate Lite I.£*.vkK, i)I,SEC3,10 systens(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK TEAK DE'll",(7-110N
<br />3.. Indicale the LEA S)t; ]:C"S'IO syll�teni(s) used to comply with. the monitoring requirements for tine tank,
<br />SIT. INIlj'C)IC INlIC)I, ON'1' I IC PFIRMANEN11Y CLOSED IN PIS{I3
<br />I. kSi l' AT I) )NI'E L ASi' L.SI i:I - MON-1111/YEAR (January, 1988 or 01,188).
<br />2, f- S"I IM l'ED t. UAN':1:'i'I"y of iLAZAi DOD in the. tank (in (3 allons),
<br />3. VVASTPkNK PIS.LEI) WFIE INERT ),IA'T"S S',:LIL? C.,' eck'Ycs' or 'NO'.
<br />I SPRIG" O IA)It'111H 1,0CM, AG11 NCIRS
<br />The stat underground storag=e tisk identification nr niter is composed of the two dihit county number, the three digit jurisdiction
<br />number, the; six digit facility number arta the six digit tank number_ The county and jurisdiction numbers are predetermined and
<br />an be obtanvd by callimy thea State Board (916)'739-2421. The, facility number'must be the same as shown in form "A". 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 agc racy prefe=rs the State Board to assign the tank number, please leave it Wank,
<br />ri, is C) r "1`t 1E LOCAL ACil(' "II I' INSP 'rs'lllE FACfLrrY TO VERIFY UIE
<br />OC°UR C"Y OF'I IS3N1k) A`I"IC3a'�S. IIE LOCAL ASI inti IS R SIO SI 3LE 1101 '1` 111 C OMPIET10N C) 111E
<br />1IA)CAL ACII:iz C `f USE ONLr I FORMN110IAF I k ti l) FOR URWAR1 ING ON13 FORM W AND ASSOCINI10.
<br />lifFNIll ARD
<br />P.O. BOX 527
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