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<br /> GENERAL IN °RI1(—NONS.
<br /> 1. One FORM"I3'shall be completed fcsr each tank for all NM. PFR .N I ERMrI"CHANGES, R. ,I OVAT and/or any
<br /> other'FAN R TION 01ANGE
<br /> . This form should be completed by ch her the 1'L?. Tk'APPL C L r or the LOCAL
<br /> AGENCY UNDERGROUNDTANK
<br /> INSP R
<br /> 3. Phnise type;or print clearly all rcgi u:e;ted information.
<br /> 4Use a hard point writing instrument, you are nn«king 3 copies.
<br /> TOP()Ir 1 ) ARS ONLY ONE rIUM'
<br /> 1. Mark an( ) in the box next to the nxitn that best describes the reason the form is being completed.
<br /> 2. Indicate the DBA sir Facility nal ne where tie tank is installed,
<br /> I. TANK DESCRIL ZION-(.C) I'I.INTl ALL L"n s-II?UNKNOWN-SO STI :I
<br /> A. Indicate owners tank 1�1y If there is a tank number that is used by the owner to identifythe tank(ex.AI370789).
<br /> B. Indicate the name of tllne company that manufactured the tank(ex,ACME'T'Ar[K MFG.).
<br /> C. Indicate the year the tank was in�tallcd (ex. 1987),
<br /> I). Indicate the tank capacity in gallons(ex.25,E or 10,Cklt)etc,).
<br /> H. 'TANK CON117SINY
<br /> A, 1. If MO'I`OR V I-"IIIC I f FUT"L,check box 1, and complete items B& C.
<br /> 2.If not MOTOR V 1111 1,"FC,Is1;check the appropriate box in section:A and complete items B & D.
<br /> B. Check the appropriate box.
<br /> C. Check the type of Slffl'OR VE II(,i,E FUEL L, if box 1 is checked in A).
<br /> D. Print the chemical name of the hazardous,ous,substance*stewed in the tank and the C:.A.x, .(Chemical Abstract Service
<br /> number),if box 1 is NO checked in A.
<br /> III. TANK C ONS T RL3 T CSN-- IAK N NEM ONLY IN BOX A,TI,C°&I)
<br /> I. Check only,one item inTYPE Of SY;'Tl',M '['ACtiK MA'['ERIAI,,, IitirERIC)R LINING asset CORROSIONI'RO1'IH717IC):`�.
<br /> 2 If OTHER,print in the armee:provided,
<br /> IV. PIPING INI R t T[C)N
<br /> 1. Circle A if above ground;circle CI if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle: or if 0111ER,priest in space provided,
<br /> 3. Indicate the LES71,I 11C-'ION system(s)used to comply with the monitoring;requirement for the:piping.
<br /> V. TANK LEAK DITITIA717ON
<br /> 1. Indicate the 1,1?A y 1 L?CI°1ON systema(s) used to comply with the monitoring requirements for the tank.
<br /> -VL INFO 111()N ON TANK PER ANI1NR"SX GIAISED IN PLACE
<br /> 2 Fs511 A .D I)A I`I IJ1 `[`USE"[)-MON'"i' f`r I°,AR(January, 1988 or 01/88).
<br /> 2. ESTIM1 10"[;1.) QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS'1'ANIC.FILLED rrni Check'Yes'or'NTO':,
<br /> APPIJ KI'SIGN ANI)i)KIE°1 1TI FORM AS I(W119),
<br /> . CI(e11ON.. R'11 E LOCAL A(7 COIF 2 -
<br /> The state underground steerage 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"snumbe , The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling tine state Board (91.6)73'9-2421.. `T"the facility number crust be the same as shown in form "lt". The,
<br /> tank nurnber may be assigned by the teat agency-, however,this number crust be numerical and cannot contains an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number."please leave it blank.
<br /> rl'IS nW,R S NSIIiUXI" ()I 'FII?LOCAL t1Cal C l IIIA:[`INS1' ISI IA( io alit' °III?
<br /> AC CY ()Ir '11I3 INFO, 170N. 171E LCt7CAI.,AGENCY IS RijSPONSIBLE FOR"lffi OOMP1,LI1'ON OF 17111
<br /> 11MAL AGENCY Sli ONLY'INIiORMN110N BOXAND FOR FORWARDING ONE FO 'A'AND XSSO(1JVJ1-D
<br /> FO -B'(s)'10 111F.1A)LIDIN€1 AI)I)FlI Sw
<br /> C/o . .1 a.1?Fb. .
<br /> DA71A PROCE&SING CT ITItsit
<br /> P.O.13O 527
<br /> F'A OU I',CA%723
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