COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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:NS'1`RU(:TI1ONS ICOR C OMPI.IfITNG FORM*E3* GENERAL IN517RUCITONR 1. One FORM"I3"shall be completed for each tank for all NEW FERMrB,PERMIT C;ITANGF-S, REMOVALS and/or any otherTANK.INFORMA11ON CHANGE 2. ':Phis form should be completed by either the PERMr.I'APF UC'.A I'or the LOCAL AGENCY lJNDfMGROUND'11`ANK INSPE I 1t. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM- 'MARK ONLY ONE M!W I. Mark an (Y)in the box next to the item that gest describes the reason the form is being cornpleted. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK T:1F>SC.° IV11ON CAOMPLE111 AIM.I'1 < S-CIS"UNKNOWN-SO SPIMI-11 A. Indicate owners tank II)#-If there is a tank number that is used by the owner to identify the tank(ex.A 370789). B. Indicate the name of the company that manufactured the tank(ex.ACMETANK MFG.). C. Indicate the year the tank was installed(ex. 19137). 1). Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.). It. TANK CONFEMIN A. I. If MO'1'0R VEHICLE FUEL,check box 1 and complete items IB &C. 2. If not MOTOR VEHIC;IA, FUEL,check the appropriate box in section A and complete;items IB&1:). B. Check the:appropriate box. C. Check the tyke of MOTOR VEHICLE FUEL(if box'I is checked in A). D. Print the chemical name of the hazardoussubstancestored in the tank and the C"..A.5. ,(Chemical (Abstract Service number), if box 1 is NOT checked in A. III. 'IANK C OMT1 .U(N ION-MARK ONE n-FM Cl-FMONLY 13,C1&t) 1. Check only one iter; inTYPE OF SYS`I`EM,TANK A"I'I✓I2IIAL,INFERIC7It LINING and CORROSION PROTECTION. TION. 1 If OTHER,print in the space provided.. 1V. PIPING INFORMA711ON 1. Circle A if above ground;circle U if underground',and circle bath if applicable. 2. If UNKNOWN,circle;or if 0711ER,print in space provided. 3. Indicate the I,E:AK D EC`TION system(s) used to comply with the monitoring requirement for the piping, V. 'PANIC LEAK DEWXT1TON 1. Indicate the LAIC DETECTION system(s)used to comply with the monitoring requirements for the tank. VT. INFORMA`nON ONTANK PFR ANIi I V(°t S`ED IN PIAC:I? I. 05ITMA'11'D DATE I.AS"T"USED- ON`I11/Y R(January, 1988 or 01/88). 2. is SsriMATI.I)QUAN`IITY of IIA7AIU)OLDS SIJIBSI'fANCE remaining in the tank(in Gallons): 3. WAS TANK E II,T,ItiT7 WFIll INEXI' 'ITERIAL? Check'Yes'or'NO'. APPLICANT muqrSl(;N AND DATI '111I?FORM A.S . )1 ° `I INS°I'ItiJ{'nON FOR I'II1?LOCAL AGENC1ES The state underground storage tank identification number is compt)sed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number, The county and jurisdiction numbers are predetermined and can be obtained by calling the State acrd(1116)739-2421. `The facility"number must be the same as shown in form "fA". The tank number may be assigned by the local agency; however,this num er crust be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. I°IS ITIE R&SI"ONSID111W OF 11113 LOCAL AC 3N( IIIA['INSt'Aa.1 S"11I?FA(31.Xry TO VERIFY 37111 ACCURACY OF 711E ORM)`I1ON. '171E LOCAL AC HN( "IS aSPONS [.I:?1;011 n1li C O 113110N Ole"IV "WCAL AGENCY USE ONLY'INFORMA717ON BOX AND MR FORWARDING O I 'A"AND A SC)C,I AMI FORM'B'(s)TO 111113 MLLOWING ADDRESS. A'I 3 011 CATIFORNIA DA'I'.A PROC'USSING CEN114,R P.O527 PARAMOUN717,CA 90-M i