|
7� 741111�
<br /> 1N!;1`RUC110NS MR COMPLE1ING 10*W
<br /> GI INERAI,1N5FRUC`.n0NS'
<br /> 1. One FORM"Ir shall be completed for each tank for all NEW PERMT17S,PERIArFC11ANGWA RFMOVAIS and/or any
<br /> otherTANK INFORMN11ON(711ANG&
<br /> 2. This form should be completed by either the PEMMIT APPLICANI'or the LOCAL AGENCY UNDERGROUNDTANK
<br /> INSPIX-ft)P_
<br /> 1 Please type or print clearly all requested information,
<br /> 7 4Use a hard point writing instrument,you are making 3-copies.
<br /> TOP OF FORM: 'MARK ONLY ow�ruar
<br /> 1; Mark an (X) in the box next to the item that best descries the reason ihe'Ora is being completed.
<br /> 2. Indicate the.DBA or Facility name where the tank is installed.
<br /> 'I
<br /> i. rANK DF-SCRIPLION-'O0MP1-HTVt ALL TIEMS-11?UNKNOWN-So STIX,FY
<br /> 11)#-If there is a tank number that is used by the owner to identify the,faidt(ex,AB70799).
<br /> A, Indicate owners tan a
<br /> B. Indicate the name of The company that manufactured the tank(ex,ACMIFTANK MFG,),
<br /> C. Indicate the year the tank was installed(ex, 1987),
<br /> 1). Indicate the tank capacity in gallons(ex,25,000 or 10,000 etc.),
<br /> IL TANK CON71WI'S
<br /> A. 1, If MO`]'OR V1;11ICLE FUIH,,check box 1 and complete items B&C.
<br /> 2, If not MOTOR V171111CLE FUEL,check the appropriate box in section A and complete items B& D.
<br /> B. Check the appropriate box.
<br /> C• Check the type of MOTOR VEHICLE' MEL(if box 1 is checked in A).
<br /> D. Print The chemical name of the hazardous substance stored in the tank- and the C.A.S4.,(Chernical Abstract Service
<br /> number),if box I is NOT checked in A,
<br /> 1,11. TANK CONS7PRUMON-MARK ONE H'EM ONLY IN BOX A,B,C&D
<br /> 1, Check only one item inTYPE 01, SYSTF.\4,TANK MlVIURJAL, INITRIOR LINING and CORROSION PROTE(71'10N
<br /> 1 If 011ffi1I,print in the space provided.
<br /> JV. PIPING INIZORMMnON
<br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable,
<br /> 1 If UNKNOWN,circle; or if(TI11HR,print in space provided,
<br /> 3. Indicate the LEAK DE�I'T�CXION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DIM, 'FC170N
<br /> Indicate the 11AK DIT!"WPION system(-,) used to comply with t It e monitoring requirernents foe the tank.
<br /> V1. INFORN&nON ON TANK PERMEtC-LaSTD IN FlAcul
<br /> 1. F-511MATED Ill'FE IAST USED-MON1111/YEAR(January, 19.98 or(11/88).'
<br /> 2. i7srimvi` )QUANITFY of IIA ZARDD US SUDIS."I'ANCE remaining in the,timk(in Gallons),
<br /> 3. WAS TANK FILLED WTHI INFKF M.,VrERIAL?Check'Yes'or'NO'.
<br /> APP11CAN.r MUSM SIGN ANi3.6 °v'rap,FORM AS YNSIC NI'EIF.
<br /> INSTRU('11ON FOR17W LOCAL AGENCIES
<br /> The state underground storage tank identification,number is composed of the Mo 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 obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form "A, The
<br /> tank number array be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> ITIS UIE RESPONSIBUXlY OF THE 1,()CAL ACA FNCY'n1X1'1NSP11(TIS'I11E IWILTITTO VIMIFY ME
<br /> ACCURA('Y OF'nH!INIX)RMA'1710N. WE LOCAL AGFNCY IS RESPONSIBLE FOR 771B COMPIIqION OF 1711r,
<br /> *LOCAL AGENCY USE ONLY"INFORMA'nON BOX AND IUR FORWARDING ONE FORM Nk"ANT)AS. N11
<br /> pORM-Ir(s)-M 111E INH IDWING ADDROSS.
<br /> ,5r,K11:?OF CA11FORNIA
<br /> srxm ;WJV1'ER RESOURCES COMIROL BOARD
<br /> C/o smm-F-Ps.
<br /> DATA PROCMING CENI`ER
<br /> P.O.BOX 5Z7
<br /> PARAMOUN'r,CA 90723
<br /> 4
<br />
|