|
l
<br /> Rgg.''d°€ggr Yg�b�Y.gg ppL4
<br /> RM
<br /> '�gJ,gga9
<br /> yy$gY.SA��mg {p��:s.ti.✓IPgyrI i�✓k._e.R.1 E�0.d.$'O �k'J�
<br /> 1 (Me 1`01110 11110 shaR be coniple Ec I for each tank fcn all Nif PERMI'T'S,PERmn, .HANGP , t` ? )1-, I:�and/or an
<br /> othet 1.!,NK 1NF0RMA`l-T(JN CIIANG11,
<br /> 1. ']'his f ".,a.h-0,�lea„m completed lay e'thcr the 1L `I' I1PL1CANF or the IO(YiL AGENCY UNDERGROUND TANK
<br /> 1, 1TlE:�4a, ??;l"}e^ or 1S'93Y€t,�s„1 35, ;a'.k -�y,a`este€1 information.
<br /> 4, Use a baro-point wrifing are making3 copae
<br /> TOP 017 lIN1'IC a'MARK ONLY ONE rnw,
<br /> e,
<br /> L ”Nark. all )in the box next to the ltern Haat Gest describes the reason the form i1,toeing completed,
<br /> 2 Indicate:t1re-1-J13A or Fe.cility name where the tank is installed.
<br /> 1, TANK I lf?,'RII'I'ION-COMPLInS Ali,rams-IF UNKNOWN-A)SPI 3
<br /> A. Indicate cvne~a tank 1 rY •• If there is a tank number that is used by the owner to id;n l[y the tank(ex. B707€37).
<br /> 13, Indicate `the; mane of the company that manufac°tu red the tank (ex.ACME TANK MFG.),
<br /> C, Indicate the year the took was installed (ex. 11357).
<br /> D3 Indicate the tank capacity in gallons(ex,25,(V)or 10,000 etc.). "
<br /> A, 1, If S1(YIFOR VEHICLE LE J£,I,check box I and complete items 11& C. q�
<br /> If no,-.. ;vg�,a°,); ",I .?Ec s_a.I l.,=,1-.c.hcck the appropriate,box in section A and complete ilems I3 & I),
<br /> C„3 w a 7 i,a Y
<br /> ,.f
<br /> ;kb.l .,c° t s ',,,10,=�a3C ;1, 3 I.r ( box"1 as checked in 1},
<br /> >riNit flhW chcn-,,I nwan<„, c r the 1 next>c�_substance store)in the tank and the C:,A S. . (Chemical Abstract Sclxice
<br /> a t f t r : ;as I1'e`l2k et."(I€ ,
<br /> 111. 11lof CCOST I1b7a."1 s13 a i,NI RK ONE”11"I'M ONLY IN BOX fa, 11,C&I7
<br /> 1. Chcck only one item in, 1'Y"PIs 01 'mI.Y, E'M,`I`ANK NIATERIAL INT17EIISC2R LINING and C C3TZROSIO I RO'I"F?,C"I10N?
<br /> 2. If£gk`IiCs'lI, pT1nt in the nkc= Pcovidled,
<br /> IV, PIPING IINIFORINNRA'HON
<br /> C ir,l. a, if s_ ,.. a,if=..i r ,lo7mim ly and circle,both of applicable.
<br /> ', If! f a,..N:C1a "`s, t .:°I0 z'H nt in, sp t e:9ro idcd,
<br /> ? J.S"d,k,,aic zhe I', ?A ti,.131 Q1 (,,1 fv, a a4r`it i 3s vtscd to :orn ply wh h.the monit:oring requ 7t'£:ment for the pips rig
<br /> ty. TANK I a"AF est e'1 9g i
<br /> 1. 1_„v t, . _ _.f a, ,`,'..°I 't,3111rf? . _e �.;�na,d ta ,.a=oe}ywsth ttae monitoring requirements,for the tank,
<br /> At, IN1'CI11t V1 010 ON N a t1i1 Iso ,.a ter„ I i. `C1,081313 81313 I ISI yC
<br /> 1aSTINf,`\TI D 131'I'?_ LAST saa>Iia mo,, I`II/�'1`,AR(January, 1988 or 01/88).
<br /> of HA, A ,D0f( S Sli[,I'l:;°NCE remaining in the tank(in Gallons),
<br /> PPI,<xCANT MU917 1U917SAC:'slaa ANT)1ar111s'1111;KORM C I:CuISI1 s `I1 I s.
<br /> The state undcrground storage tank identhic,atson numb.er is coma used of the two digit county number,the three digit jurisdiction
<br /> number, the,six high fac:lkcy cumber and the:six drat tank nutmben The county and jurisdiction numbers ars`predetermined and
<br /> call be obtai.ewd 3T c Ling ,he State.Board(716)7=39,2421, The facility number must be the same as shown in form "A', ''he
<br /> tank nor.aer may th,assigned lry the local agcncy9 however, this number must be numerical and cannot contain an alphabet, If
<br /> the local agency prefers the State bard to assign the tank number,piease leave it blank.
<br /> 1`1'IS`1111. It~IC`P+1,NS31iI1 '1, Cy1,T11t,LOC:, 1.,A(3IaI CI°1' '111AT'1JNSPI CW1 '17W F C1111'Y TO VIAI II 11U!
<br /> ekllX_17IIAC'Y O 11115;Is as _>I1.axIJ 11".,N, 1111<1,00M,AGENCY Y 1S 1U S1'C)NSI331.Is PORI I1 C,OMPLF-1100 OF'1111I
<br /> e!1GElaa,Y 13SE ONLY' 1NFUIIMA3101d BOX AND 17OR FORWARDING DING CS A FORM'A'AND SS()C1YV..I'1,,D
<br /> y 1`a,'Iys a A'llyg 111'S01.110 i,CONTROL 12t312I�
<br /> .C'I.BOX 52" k,
<br /> PARC a1`N1",CA 90`723 f
<br />
|