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g <br /> IMIT17RUC17ION&I R COMP111 IN)RM`B" <br /> G IST T C)TV4 <br /> 1 ` eCSR "j3"sjsA to completed for each tank for all E PERMtIz,,I'T?IZMI`I'C;ITA GM-S, R17MO AI,S acid/or any <br /> outer T N ) A'T IC CHANGE. <br /> This form should be completed by either the T? 1'AP PT..IC 'or the LOCAL AGENCY UNDUIRGROUND TANK <br /> 3. or print c ar y all requested information. <br /> 4. Use a hard point writing in true c;nL,ynptarc r�mint,3 copies, <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name:where the tank is installed. <br /> . TANK :g`: IJ0N_COMPlinli All,TrTtMS-IF UNKNOWN-SO SPFCIITY <br /> A. Indicate owners tank II)# -if there is a tank number that is used by the owner to identify the tank(ex.AT171789). <br /> II. Indicate the name of the company that manufactured the tank(ex.AC;M .Tf! V MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25#)0 or 10,000 etc.). <br /> H. TANK COITITWn' <br /> A. 1,If MOTOR VEHICLE FUEL,check box'I and complete items II&Cn: <br /> 1 if not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items II&D. <br /> TI. Check the;appropriate box: <br /> C. Cheek the type of MOTOR EHI LF?FUEL(if box 1 is checked in A). <br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C;.A.S. . (Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> HL T )l UCITO -MARK ONE TI IM ONLY IN BOX aA,B,'CA&I3 <br /> I.. Check only one item in TYPE OF SY TE M,TANK MATE MAL,INTI SRIOR LINING and CORROSION PRCE"T`EX-710 . <br /> 2. If OrIHFIF priest in the space provided. <br /> . PIPING CI IN I. O <br /> 1. (circle A if above ground;circle U if un le:rgroun& and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if CE"1HER,print in space provided. <br /> 3. Indicate the LEAK Ly 3`1 C'T"ION system(s)used to comply with the monitoring requirement for the pipin& <br /> V. TAN LEAK DIT"FFXa 111 <br /> 1. Indicate the LFATC I;Ff'F'1C I'1O system(s)used to comply with the monitoring requirements for the tank. <br /> I. INFORMA110N ONTANK PERMAbIEN".T"I C'LOSM)IN PIACE <br /> 1. ISI'1N1ATI,,D I)ALI: >S"T'US I)-M01\11"11/YEAR(January,1.988 off°M/88). <br /> 2. ESOMATED QUANT11TY of HA7Al2:I3OUS SUBS"T`ANC E remainingintthe tank(in Gallons). <br /> 3. WAS TANK V1LL,1sI7 WITH INEZ T MATERIAL?Check'Yes'or'NO'. <br /> Ai-,Fu l'musr SIGN AND 3x'YIE 11111 FORM AS IMHCAITD. <br /> 1 ,1°12 J(°C'TC3 I )R I"1II3 LOCAL ACm1:NC:II:sS <br /> The state underground storage 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 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 may 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 /> I'IS"`III.RFS. .MIBff rI'Y OF'I'TI?LOC/td,AGINCY111AT INSTE(71 `fl11E FA('<II;l"Y'TO VERIFY 31111 <br /> A C" 'OF 11113-INFORMN110N. '1116 LOCAL A(A C Y IS RESPONSIBLE FO 'NIE COMPLINION 017171 <br /> AGENCY USE ONLYm IN17ORMNITON BOX AND'M R ARDI G ONE I ORIA�A° ANI)A> Cl/V110 <br /> FORM-B-(s)TO 11111 F011DWING ADDRRSS. <br /> ATL,.O (ALIFORNIA <br /> T I : I :R REM° URCE NI°ROL BOARD <br /> TEAT PROCT&SING C:rM`3'I <br /> P.O.BOX.527 <br /> Pay V OUNI",CA 90-M <br />