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<br /> INS17RUC7110bbi POR COMPLEqWG,I "3"
<br /> I, One FORM"i3"shall be completed for each tank for all NI1rW PERMI`'S,PF r1'CIA GE , MOVAI S and/or any
<br /> other TANK NI A'ITO CII ' G1
<br /> 2, This form shouid be completed by either the PERMITAPPUCANT or the LOCAL,GLNC," €I I) tf, C UNI)TANK
<br /> 3: Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are makin§3 copies.
<br /> '7OP OF IAC) 4-14xi k 0-M, ONE
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<br /> 1, Mark an�X),alt thgN o,�next to the item that best describes the reason the forest is beim,compl,cd.
<br /> h
<br /> 2. Indicate t T3 d aczlity name where,the tank is installed,
<br /> A. Indicate owners tank Il)#-If there is,� task number that is used by the owner to identify the tank(ex.AI370789)„„
<br /> 13. indicate the name of the company that manufactured the tank.(ex..AC ME TAMC MFG,),
<br /> C. Indicate the year the tank was Installed ex, 1987). ”
<br /> D. Indicate the tank capacity in gallons'(esr.25,000 or 10,000 eti,'11,
<br /> A. 1, If MOIIOR VEHICLE EL,check box 1 and complete items I3&C:.
<br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate bex in section A and complete items B&D;
<br /> I3; Check the appropriate box.
<br /> C, Check the type of MOTOR VEHICLE 'EL(if box 1 is checked in A).
<br /> D: Print the chemical name of the hazardous substance stored in the tank and the C;.A.S. .(Chemical Abstract Service
<br /> number), if box 1 is-NOT checked in A.
<br /> ,
<br /> III, rANK com.TrRucmm-mAlzjtom,$mw oNiy IN BOX A,I3,C&I)
<br /> 1. Check only one item izi'I"YPE OF SYSTEM,TAN MATERIAL, INTERIOR LINING and CORROSION IbItOTE(7I"0N,
<br /> 2. If 0.nIER,print in the space provided.
<br /> IV. PIPING A]IC)Pd
<br /> 1. Circle A if above ground;circle 1J if underground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or)f COTTER,print in space provided.
<br /> 3. Indicate the 1, K DEF C;. O systent(s)used to comply with the monitoring requirement for the piping,
<br /> V. YANK LFAK DI31W,(711ON
<br /> 1. indicate the LEAK 7?}.1:'I C)ri system(s)used to comply with the monitoring:requirements for the tank.
<br /> 3. INIURMKIION ON TANK PERMANEDMN CLOSED IN P AC:T?
<br /> 1.` ESTIMATED DATA LAST USED-MOMI'I�I/Y R(January, 1988 or 61f88).
<br /> 2, EST1.MATE1),.9UANI'rIY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3; 'SAS TANIK pfLLE D WITH INERT MA'[`ERIAL?Check'Yes'or'NC)'
<br /> APPI 1CANr MUSrSIGN AND DA '-Iii 17ORM AS INDICATED.
<br /> I a II("I10N 17C)l MIR LOCALACI r
<br /> The state underground storage tank identification number is composed of the two digit county number,the three digit jurisdiction
<br /> number,the six digit facility number ane'tho six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be Obtained by calling the State Hoard t916)739-2421. Tho*facility number must be the sante as shown in foram'A'. The
<br /> tank number may be assigned by the local agency, however,this number must be numerical and cannot cd4tain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> rl'IS IIIE RESP N I.I" Y F'1' C° AGINCY T IMI"INSPI »I'S TIII?FACIL "1"Cl VII T1113
<br /> A RACY 011"11111 INFORMS110N. 11 I,AGENCY IS RESPONSIBIX FOR 11111 IJUION-101?11 113
<br /> C L AGINC'Y USE ONLY"INFORMi ITTEX AND POR FORWARDING ONE IK) `A"Ali ")CaIA9.10
<br /> FORM-1r(s)TO111E FOLLOWING ADDRESS.
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<br /> r' 't " "t ° SIA <WATER R1WUW,W'C-0N`rRQ1.WARIX �
<br /> C/o wx I?I".s.
<br /> i),a rA PROCESSING(M '3It
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