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INSMIIC HO S MR C:C)MPI ft'Ih"� ) 41I" �
<br /> GENERAL I sT"ILt1C° ON&
<br /> 1. One IaC`3RIM"C3"shall be completed for c;.ac°lt tank for 0 NEM 111',XMITT'S,PER 1'1'01AP CA , RIB tO At S find/or any
<br /> other TANK INPORMN110N CHANGE
<br /> tGE
<br /> 2. This form s'tould be completed by s ether ,er. P1,7,* I"f"AI P1JC A,*1*,sr the LWAL AGENCY UNDERGROUNDTANK
<br /> 1 'lease type or print clearly all req estedv'iforrraflon,
<br /> 4. Use a hard nt writinginstrument,'you alre nsaking 3 aspics;
<br /> TOP OF MMM: 'MARK ONLY ONE t'IE "
<br /> 1. Mark an (X)in the box next to the itein km t gest describes the re, on the form is being complc led.
<br /> 2. Indicate the DRA or T`aac$lity runne whc e 'n, tank is insttajled;
<br /> L TANK DIES.JtIVITO d- C"OMPLIM-e All,MiMS-If?UNKNOWN-SO @1FX'I1
<br /> A. Indicate ov,, ers oink TI) -If these, is a fark number that is assert by the owner to identify the tank(ex.ACB7(,)789),,
<br /> M :Indicate the natne of the company that .�,ania{"aetcare the tank t x.,AC'111;'I`AN t'(3,).
<br /> Com, Indicate the year,the tank was installed ( x '1987).
<br /> D, Indicate the tank capacity in gallons (,x 25,rXXt 0r 10AW etc,",
<br /> !t. B. If Cl"I OR Vl311I0,11,!Urfi a,check box l and complete ite trsa T3&C
<br /> 2. Tf not NVYI'OR VEHICLE FEL,check the appropriate box in section A and complete items i3 ds D.
<br /> T3. Check the approprime box.
<br /> Cl. Check the type of MOTOR VE,"HIC111,11,FUEL(if box I is checked in A).
<br /> IJ, Print they chemical name of the hazardous substance stored in the tank and the C.A.S,#.. (Chemical Ahstnac t Service
<br /> nuanber) if box 2 is N01'checked in A.
<br /> M. TANK C:ON 1"RUC.1"1 ) MARK C) 1<MM ONLY IN TMA,IB,C:&I7
<br /> 1. Check only one item in'I"'PE 0ta'.S S"I"FA1,TAMC MATERIAL W11 RIOR LINING and CORROSION PRC7'I"I.,f" 1ONT.
<br /> 2, If 0111ER,print in the spacer,providcds
<br /> IV. PIPING INFORMM70N
<br /> 1, Circle A if aboveground;circle IJ if underground;and circle both if applicable,
<br /> 2. If UNKNOWN,circle; or if OTHER,printin space presided
<br /> 1 Indicate the LEA S`3Ii"1"t3C.1ION systena(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK IMAK I)t,117MIO
<br /> 1, Indicate.the IAI)I.<I"I C"PICT;system(s) used to comply with the monitoring requirements for the tank.
<br /> V1. tk)R A'IION ONTANX PTIRMANENFLY CLOSED IN PLACE
<br /> 1, ESTIMATI:'D I3A"S"Ea Us'I'USED_ &IC) T`TII I rklT (January, Icing or 01/88).
<br /> 2 i-sI1mr1"I'Ia.IJ QuA-,Nrrrj,y of HAZARDOUS SUBSTANCE retraining in the tank(in Gallons).
<br /> 1 NWASTANK FILLED W111I INFR"T"'v1XI';ICTAL? Check'Yes'or'NO',
<br /> II S I'RUC7110 FOR"ITIE LOCAL AL A E C;1.0i
<br /> The state underground storage tank identification number is composed of the torp digit county number, the three davit juris'di'rion
<br /> number,the sax digit facility number and the;six;digit tants number. The County and jurisdiction numbe tars°predetermined and
<br /> can be obtaaincd by calling the State Board (916)7:39-2421: The facility number:a uM be the same as shown in form "A", The
<br /> tank number may be assigned by the local aagetincy; however,this number must be numerical and cannot contain an alphabet. If
<br /> the'Ictcal agency prefers the Citi°e Board to assign the tank number,please leave it bkink,
<br /> ACCURACY 01* IIIH INFOR A310 . WE LO(AL AGENCY S RESMNSIBLI<M "I"IU-? "OMPI I31O C WME
<br /> "I.. a AGENCY USE ONLY"INIZORM a111O W)X AND POR Tr R AR1)ING ONE FORM W AND AMMMED
<br /> I W(s)IX)'11111 FOLLOWING,ADDRI;M&
<br /> 917ME OF CA11MRNIA
<br /> aMll3 A" IR Rl:xtaOURC"'I-S C"C)IV 1 R01>I1C AR37
<br /> C/o&WsT ps,
<br /> DATA PR6) .Ja,S,*T NG C:IBS IER
<br /> P.O.IM 527
<br /> A MOUM',CA 9qM
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