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.`1'ILLT . ONS FOR COMPLMING FORM*80 <br /> GENE I< ALT IC)NSa` <br /> 1. One FOR "W shall be completed for each tank for all NEW PERM1rI.N, PERMrr tiF-9, 12EMOV°A S anti/or any <br /> other TANK INFORMA17ON CIIIANCI <br /> `, This form should be completed by either the PEI 1'APPUCANT or the I.,OCAL AGENCY UNDERGROUNDTANK <br /> INSPECrOPL <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard paint writing instrument,you are making 3 copies. <br /> I'OP OF FORM-"MARK ONI.Y ONE 1`11424" <br /> 1. bark an (%) in the boss next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the D A or Facility name where the tank is installed. <br /> . "TANK DF—' e i ON®CO PI d3`n!AIL M9WS-IIS UNKNOWN-SOSPECIFY. <br /> A. Indicate owners tank I a If there is a tank number that is used by the owner to identify the tank(ex.A1370759). <br /> B. Indicate the nacre of the company that manufactured the tank(ex,ACME TANK MFC}.). <br /> C. Indicate the year the tank was installed(ex. 1.457). <br /> T), Indicate the tank capacity in gallons(ex.25,000 or 10,OW etc.). <br /> 11. 'TANK Cel) $NI 5 <br /> A. I.If MOTOR VI<IIICI..F FUEL,,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEIIIC'I,E FUE1,,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR 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 I is NC3'I'checked in A. <br /> III. TANK C ONS UC 17ON-MARK ONE TFEM ONIM IN BOX,A,11,C,"&E) <br /> 1.. Check only one item in TYPE 0714'SYS7FEM,'rANIC MATERIAL,RIAL,IN"IERIOR LINING and CORROSION PRO'17L CAN. <br /> 2. If 0`11TER,print in the space provided. <br /> PIPING �C)IL ATION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle: or if OTIIEF.print in space provided. <br /> 3. Indicate the LAIC 1)I7713 C)N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IEAK DVIMCFION <br /> 1. Indicate the 1.EAIC DEIT.CTION system(s)used to comply with the monitoring requirements for the'tank. <br /> L INFORMATION ONTANK PIM ANIINIIR C SI93 IN PLACTi <br /> 1. .5'I7 ':I'El)DATE 1 AST USED-MON`I`II/I'I:AR(January, 1088 or 01/88):- <br /> . FSTIMATED QUANTITY of IIA2.AItDOUS SUBSTANCE E ret aining in the tank(in Gallons). <br /> 3. WASTANK FILLED WITII INERTmA'TER]AL°?Check°des°or.'N '. <br /> APPI 3C° `musr SIGN AND DWILT 111111 FORM AS IN13IC',.NIM. <br /> S717RUC HON IC°I°III?U3CAL AGFNCIIES, <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 N.obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in force"A". ne <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 agency prefers the State Board to assign the tank number,please leaved blank. <br /> 1°r 1S-rm REsPoNsimmx owi i m i AGENCY-1-1IAT INSPECIS TI IE FAcany i o witury I nit <br /> ACCURACY. 01717111 INFORMNnON. 1IIL I C"AI.AGENCY IS RESPONSIBIX,FOR 1°I1E.C_C➢ P11 `IC)N 01-1'I7III <br /> 'I IA AGENCY US'1?ONIN'INFC)II A°HON BOX AND FOR A SING ONE FORM OAO AND A. ° `I1a?1) <br /> FORM"I3"(s)TC3 17111 E011.CI ING ADD S. <br /> SIS ...OF CAIJIURNIA <br /> SI VnI WA7113R RF—SOURCES CONTROL BOARD <br /> /o sma?np=s. <br /> BATA 1"II.C)COSSINC CMNTER <br /> P.O.BOX 52'7 <br /> PA MOO ,CA 90723 <br />