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INSI'RUCnONS FOR P .a NG€ *€3" <br /> GENERAL IS'FRU TONNS <br /> 1. One FO "I3"shall be completed for each tank for all NEW PERWON PERMrr CTMOMS, €Y OVAI and/or any <br /> other TANK€NC LC 'ITON CHANGE. <br /> 2. This form should be completed by either the PERMrr Appucwr or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECMR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard:point writing instrument,you are making 3 copies. <br /> °ITIP CSL Pow. MARK ONLY ONE r€ :a " <br /> 1. lark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility nacre where the tank is installed. <br /> L TANK D13 'RIIF ION-COMPLFFH ALL rPEMS-€P UNKNOWN-SO FW <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.,A.I370789). <br /> B. Indicate the nacre of the company that manufactured the tank (ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> 13. Indicate the tank capacity in gallons(ex.25, or 10,000 etc.). <br /> 11. TANK COINMINTS' <br /> A. 1.If IvIC3"I`OR VFHIC"I..I F'C.liL,check box 1 and complete items 13&C. <br /> 2. If not 1a1C3'[OR YI3IIIC LE FUEL,check the appropriate box in section A and complete items 13& D. <br /> B. Check the appropriate box, <br /> C. Check the type of mCTOR VEHICLE FUEL(if box 1 is checked in A). <br /> I). 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 N€I°f checked in A. <br /> IFI. TANK C ONSI UC 11ON ONE 171 ONLY IN BOXA,13,1"&13 <br /> 1.. Check only one item in TYPE OF SYS"TE ,TANK MATERIAL,INTERIOR LINING and CORROSION PROIER7110N <br /> 2. If OTITER,print in the space provided, <br /> IV. PIPINGA'11ON <br /> 1. Circle A if above ground;circle U if underground;and circle troth if applicable. <br /> 2. If UNKNOWN,circle; or if C3I'HER,print in space provided. <br /> 3. Indicate-the LEAK A L'E7l13C'I'I0N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANKLEAKDHIEGFION <br /> 1. Indicate the I.,; TC DE1.7L ON system(s)used to comply with the monitoring requirements for the tank: <br /> VL INIURMATION ONTANK P13 NENI'LY Ca€ E0 IN PIAC <br /> 1. E.'T1 'I`ED DATE€AS'T USED m (3MLII/Y AIt (January, 1988 or 01/88): <br /> 2. ESTIMATED QUANTITY of I-IA MEDIUS SUBS`1'ANC E remaining in the tank(in Gallons). <br /> 3. WAS TANK 1711 ;E3ta WITH INERT mA`I RIAL,? Check'Yes'or'NO', <br /> APPLICANT MU917SIGN ANIS DA'ILT 111111 FORM AS INDICN11M. <br /> STRUC 11ON nIE LOCAL AGENC HIS <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 and the six digit tank number. The county and'jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board(916)739-2421. The facility number must be the sane as shown in form "A". The <br /> tank number maybe assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the State Hoard to assign the tank number,please leave it blank: <br /> rf 1S° I RESIONSIBILrIA 01VITIE LOCAL AGENCY Y"MAT I SPWI `I i I7ACII r Y TO VERIff 1111i <br /> ACCURACYOFT1111INFORMAITON. IIIE LOCAL AGI NC:Y IS RESTONSIBLE FOR 7 IIE C:C)MPLHI€ON OF`L k1131 <br /> *LOCAL AGFNCY USE ONLY'INFORMN11ON BOX AND FOR LSA ING ONE FORM WAND ASSOCWIED <br /> FORM "(s} '1711.1 11,0 ING ADDRESS. <br /> STAT`?OF CALIFORNIA <br /> NI11, X1`ER ROSOURCBS CD C)1 BOARD <br /> C/O S.W.E 133 PS <br /> D IA PROC17,SSING C1W11,R <br /> P.O.BOX 52°7 <br /> PAR,'kMOUNr,.CA 90M <br />