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T, . UC HO S FOR COMPLITIING FOR 111
<br /> GENERAL.I FRUCiICSa
<br /> t. One FOR "I3"shall be completed for each tank for all N13M PERTkM S,. !R rr CHANGUS, RPMOVAIS and/or any
<br /> either TANK INIX) MA11 N CHANGE
<br /> 2. This form should be completed by either the Pig i' PLICAMI'or the O( L,AGENCY UNDTIRGMOUNDTANK
<br /> INSPEC'"T`C°I2
<br /> 3. Please type or print clearly all requested information:
<br /> 4. Use a hard point writing instrument,yoga are making 3 copies.
<br /> TOP C)Ir IX)Itz .'MARK ONLY ONF'CI`l Pte"
<br /> 1. "viark an )in the box next to the item that best describes the reason the form is being completed.
<br /> � .
<br /> �. Indicate the DBA c,> h�n�star=�>,,,,,where: 3r„ tankisanstaiiad,
<br /> I. TANK I3ES('III ITT -C )MP11'Fl1 At,[,I'MMS-IF UNKNOWN-,S0 S II01
<br /> Indicate owners tank ) If there is a tank number that is used by the owner to identify the tank ex. B70789).
<br /> B. Indicate the name,of the company that manuf`actur�-d the tank(ex.ACME IAN FG.).
<br /> Indicate the:year tlsc, uwni,was tn,, ,,ted(ex, 198
<br /> I). Indicate the tatti cafeld y in i li n's fee,25"( or 10,000 etc.):
<br /> IL TANK CONTOUNT17S
<br /> A, 1. if A1(')``()R VItiiiCLE i UE!,,chockbox land complete items I3&C.
<br /> 2,If no, MOTOR y'I Iiit I,i IT"F1,check the appropriate box in section ti and complete items I3& D,
<br /> Check the approm-nue box.
<br /> C, C heck the type of C`i�C3 ie?L;CI�,I°L L:(if box l,is chcck:eci in< ).
<br /> D, I'r nt the the.nkat name of the h a,ardous substances stored in the tank-and the C,A,S, .(Chemical abstract Service
<br /> nui tber),if box 1 is tN(M'c hea ke.d in As
<br /> 111. TANK COMFI&LIC"hl -MAI4%" C)NI� HIM.ONLY IN 13OX A,13,C
<br /> 1. C perk only one item in TYPE 6 E 0I'ISYS"I`FM,`i`.ANK MATERIAL, IliIT!RIC)IC LINING and CORROSION PROTIIL:I°10N:
<br /> 2. 1f C TI[E. ,print in the space provided.
<br /> IV: PIPING INMRMA11C)
<br /> 1. Circle A if above ground; circle.U if underground and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or if 011I1aT,print in space provided.
<br /> 3. Indicate the LMK f)EI1;C71ON systemns) used to comply%vith the monitoring requirement for the piping=
<br /> V. TANK LMK DITITMON
<br /> 1. Indicate the I-EAim -71"Cl ON system(s) used to comply with the monitoring requirements for the tank.
<br /> VL INF()RMA'I10N ON TANK PERM A i NOM CL SED IN PLC:
<br /> 1, FSTIMAT D DNIT LAST USF -MONNrTTI/Y ,,AIL(January, 1988 or 01/88). -
<br /> 2. 1-STIN VI'l-,I)OUATVrl']Y of HAZARDOUS SUBSTANCE E remaining in the task(in Gallons).
<br /> 3. WAS"1ANfi itlLtsED WITH I INTE.R T`MA'I ERIAL? C:iaeck'Yes' or'NO
<br /> APPT L(ANF misrsiGNg Am)DKIMUTE FORM AS INDIC
<br /> t. LtMO FOR'11111 DC L AGENCHIS
<br /> 11re state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number,the six digit fncitity 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. `lite facility number must be the;same as shown in form"A'. The
<br /> tank nx aster may be asshmed b,the local agency;however, this number mustb€numerical and cannot contain an alphabet. If
<br /> the loc ai agency prefers the Slate Board to assign the tank number,please leave:it blank.
<br /> CIr 3S T-U!, USPO SHMIXI'Y OF UTH U)CAL GIs. (;Y' IEMr SPI1.CI'l"i"ILIA FA('IL, 'IX)VERIFY 111E
<br /> ACCURACY OF 111F,INFO iMA`n.ON. `11113 LOCAL AGENCY IS RUSPONSIBLE FOR 11JE COMPLE170N OF 37111
<br /> '11)(W.AGEINCY LTSI ONLY'INPORMNnON BOX AND IIOR R)I WARDIN 3 ONE FORM W AND ASSOCIATED
<br /> FORM-W(s)TO'I11 OI.L OWINGI) RI-£te a
<br /> :/o . .1lu-P-&
<br /> DATA PROCESSING CE MI°E/I(
<br /> PDC OX 527
<br /> P OUNI',CA 90723
<br />
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