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<br /> 11491RUCIIONS F()R COMPLE,IINC3 . R 'Tr
<br /> GFMIRAL 1NfT1'RUC`110N,1;-.
<br /> 3. One IaCIRM"L$";shall be completed for eac.lr tank:for all NMN FIFIRAMITS,PRRM"1'C`1JANGhS, EMOV is1;and/or any
<br /> otherTANK RVORMA110NCII SCSI,
<br /> 2. This form should be completed by �`-v l I?I I`I'�I' 3,rt I'r>r the C..O,(: LI"ENC UNDEIICa SOUND`IAN
<br /> 1 :SP (.7R)II
<br /> 3. Please type or print clearly all requested information.
<br /> 4: Use a hard point writing;instrument,you are nkaksng;3 copies.
<br /> TOP OF FORM:*MARK ONLY ONE rn.or
<br /> 1. Mark an(X)in the box next to the iter, that best describes the reason the form is being;completed.
<br /> 2. Indicate the DBA or Eeacility name whcrc the tank is installed,
<br /> 1. TANK DYWRIVIION_,(70MP;H T3 ALL TIENISx-IF UNKNOWN-Sy)S111r1frf
<br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.AB7)789).
<br /> B. Indicate the stance of the company that rn anufacturcd the tank(rx : C,' I,T A FG,).
<br /> C. Indicate the year the tank was installed (ex. 11987).
<br /> D. Indicate the tank capacity in gallons (ex 25,0M or 10,0to etc.),
<br /> IL TANK CONIIWn*
<br /> A. `:L If MOTOR VEHICLE FUEL,check box I and complete items I1&C.
<br /> 2,if not MO7'0R VI✓IIIC',LE.'FUEL,check the appropriate boat in section A and complete items I1 A D.
<br /> I3, Check the appropriate bcix.
<br /> C. Check the type of MCJ"FOR VEHICLE FUEL(if box 1. is checked in F1).
<br /> D. Print the chemical name of the hazardous substance:stored in the tarik and the C:.A.S. . (C:hernical,Abstract Semice
<br /> number),if box 1 is NOT checked in A.
<br /> III.. "TAMC C ON!9 LOCH°O -MARK ONE Tn'Im ONLY IN BOX aA,Il,C:&1)
<br /> 1, Check only one items in TYPE' OF SYSFF3M,°E'ArNK MArERIAL,IM` RIOR LINING and CORROSION C'ItC)"I7"(TION.
<br /> 2. IfOTHER,priest in the space:provided.
<br /> IV. PIPING INPORMKnON
<br /> 1. Circle A if above ground;circle; U if underground; and circle;both if applicable.
<br /> 1 If UNKNOWN,circle or if C)THE P,print in space provided.
<br /> 3. Indicate the I,I"AK DEFEi.C.7ION systems) used to comply with the monitoring;requirement for the piping.
<br /> V. TANK IFAK DE37EC711ON
<br /> 1. Indicate the LEAK DE'l1 C"&`ON systern(s) used to comply with the monitoring requirements for the tank.
<br /> I. I'NII)C IAW110N ONTANK PERMANEN11M CLOSED IN PI CI l.
<br /> 1. I° 'TI U[k"I"E I)I)/t'I'Is I S'I"Cl4I i)- I6)Im1"IEJ I-AR(January, 1988 or CPl/88).
<br /> 1 I?S,lT%lr1TI I)QLrA.'°,''I'1TY of IIAVA1U)OL;S SLJI3SI"ANC;E' remaicsin in the tank(in Gallons),
<br /> 3, WAS TANK FILLED WITH CNI:;ilx p Afial'111,,I'CIAL,r Check'Yes' or'NO',
<br /> PP11C M7 11Sr SIGN AND 1)XI"CI'1 CII.',I ES' AS I I)IC;aA'I7:I).
<br /> IN,';s I,J IIDN I It."111.13,LOCAL AC's!NCICLaS
<br /> The state underground storage tank identification number is composed of the two digit county number, the three divit 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 may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet, If
<br /> the local a'e cy prefers the Stafe Board to assign the tank number,please leave it:Manic'.
<br /> I`I "IT1I3 RESPONSIBILITY OF THE LOCAL tACxI7 ( 1C1 I`1 SIa'1C»l S'11113 F C1L I"YY TO VERIFT 11111
<br /> AC(IJRACY()1111112 INFORMKIION. 111H ID(AL AGENCY IS' 'aSPONSlB11i M R°CI1I3 COMP11HION OF 11113
<br /> ILOCAL AGI`a, " 'LI4"I1 ONLY"INFORMNIION BOX AND FOR FORWARDING ONE FORM'A'AND x&SO(UpIlD
<br /> MRM-B-(s)TO-IME,FOLIA)WING,A13I)iLOSi.
<br /> XDVIE OF(". I.IIrOR I
<br /> S1`IT!WNIER RE-SOURCES COMI"ROL BOARD
<br /> C:/t7;Sw .I1.Rp.S.
<br /> DATA PRO(Cr" INCeC.'I NIER
<br /> P.O 13C) S2 T
<br /> PARAMOUNr,CA 9077-3
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