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CmT NBI L If°I5I"Tt1., 11ONS:
<br /> 1, One 1;t7RM "11"shall be completed fo ^ tank for all PERMrr C . CY �x R11MOVALS and/or an
<br /> otherTANK WIORMIV TO C°1'1AN ,,";.
<br /> 2. This room should be completed b ,tiay., .<.c 7 FRM_r1`aiPP1JC:NNr or the IDCAL AGENCY UNDERGROUNDTANK
<br /> 3. please type or print clearly atl tc;questc(,, ,m,tsrinaflo .
<br /> 4, Use a hard point writing instrument.,st,,u are making, copies,
<br /> TOP"01,I •'MARK ONLY ONE rJ11W
<br /> 1. Mark an ()C)in the box next to the itern that best describes the reason the form is being completed.
<br /> 2. ''Indicate the DBA or Facility name whwre the tank is installed.
<br /> 1. "IAN 3CL C1 Irn0 -C".0 1°I, y111 Au.nuw,,-IF UNKNOWN- ' t°'1# C
<br /> , Indiccu:owners tank 61) #- If there is a t jrtl,number that is used by the owner to identify the tank(ex,A1170789))
<br /> B, Indicate the name of the aonip any than r"izoafactured the tank(ex,ACSIETANK MFG).
<br /> C. Indicate the year the tank was installed (";, 1987).
<br /> D. 'Indicate the tank capacity in gallons, Inc,15,000 est 10,000 cta.).
<br /> IL TANK(X)NIIININ
<br /> & 1. It xtQTf,.;ltt I�i11CIX 111113,,chrei, tach 9 and complete items It & CP.
<br /> 2, If ryas c=C7"I`t`F1C "1i111(..I.1,lalil'.i.,check the appropriate brw 1n section A anti complete,items 11 1f,
<br /> 11, Cbeck the appropriatte latae,
<br /> C. Check tht type,of MOTOR VI'111(l T I'lll 1 (if box 1 is checked in A),
<br /> 1), liras, stud ,henlictal n=attic°of the ha ardotil;substance slor°ed in the tank,and the CA,S4,(Chemical Abstract SL"ryire
<br /> nts,rf•s.�7, i`box'I is in A.
<br /> 111. TANK C ONSWICIX-3100-MARK ONE rrm. ONLY IN H(')X A,%Cd&0
<br /> 1. ' Check only one item in TYPE OF SYqVm,1ANK M 'I"I IAL, 11 °I"t;l 10R,LINING and CORROSION IsROTI:f7110N,
<br /> 2, If 0`1"1la"nt, print in tie space provided.
<br /> 1, ' Circle A if above ground;circle U if underground-, and circle hot'It if applicable.
<br /> 2 if UNKNOWN,circle; eat ii`0'111E.k print in space provided,
<br /> , Indicate the IaFHAK l E17f ,110ti s,vstcrn(s)used to comply with the'monitoring requirement for the piping,
<br /> V, TANK LEAK DFrIX1110N
<br /> 1, ` Indicate the 1,I:AIC flyl"f'S:t;I°ON sy"sterst(s) used to comply with the:monitoring requirements,her tilt tank,
<br /> 7. IlS`i'J I `1`l T3 DATE 1A%T USED-MON['11/YEAR (Januaaa°y, 1988 or 01J88).
<br /> 2. I;S'I"I�IA'11 i) (.}I.t NI'I"T`Y of i[AZARDOtiS;UBC 1'FxNC E rerrsaniftt in the tatstk(iia(Malleins).
<br /> I" 1II,[,Ia1)W1111 I°vt:',1t1 MA'11i 1111"s Check'Yes'or'N(Y., WAS
<br /> 1 PI.IC munSIGN AND T7KI`H"1°11111101 &S, INDICA110,
<br /> INS'17RU(7110N FOR 111E LOCAL AGIN(IlLS
<br /> The state underground storage,tank identification munticr 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 ssl.aunnt'd by catling the Suate Board (916)719-2421, The facility number must"be the same as shown in form"A". °Ilae
<br /> tank number may be assigned by the local agtn y; however, this number must be numerical'anti cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the taitlu number,please leave it'blank
<br /> .
<br /> 1I`IS°11 7?1 I?SI'O SIBI1°fi'Y OF 11111 LOCAL C"x7"? a `11" "1' NSP ,1 S"1"1111 FA(,Vr1YT0 VERI"Y"C"ICl"1
<br /> ACCURACYOF 1117;IMIORMNIION. 111(1 LOCAL A6124CY IS RILL NSTRI,II IDR 11111 1 C O 1131100()P T1113
<br /> *LOCAL llfN(Y USE ONLY"INFORMS110N BO ND FOR#0kWARDING ONE Dalai*A* D a SSOC.IXIMD
<br /> )R "'[1"(n)"i`tI"Mil IULLOW[Wii ADDRIISS,
<br /> SEA711.W)VIER RUS4'URCHN COMMOL OL D
<br /> C/o sm.li?u1 .t"a.
<br /> 11.0.I1C)1C 52"7
<br /> ISA OUNI',(A%YiT3
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