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<br /> SI7It.UC110NS , `A M
<br /> T Cert t6R "B"shall a completed for each tank for all NIS ERM s, �Ia12 £' ` ES, REMOVALS and/or any
<br /> other TANk I IC "I'ION C"IIA CI11
<br /> ` 0 ,should be completed by either the �I� I` 'PPI or the LOCAL AGE UNDERGROUND`I`
<br /> 3. Please type or print clearly all mqu st€d information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> TOP OF FORM:;" RIC-ONLY,ONE Irl , ..
<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'L'BA or Facility narne where the tank is instaited.
<br /> 1, TANK )IigSCR ITT -COMPLErMi All,Y11 S®TIS UNKNOWN-So SP`MIry
<br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex,t`A1370789).
<br /> B. Indicate the name of the:conspany that manufactured the tank(ex.AC;I°a E 'AAV. FG,).
<br /> C;. Indicate the year the tank was installed (ek: 1987),
<br /> I). Indicate the tank capacity;in gallons (ex,25,000 or 10,000 etc,).
<br /> II. TANK CONJI.WrS
<br /> A 1.If lvifl'IOR E111 ,1t 1 U12,a,check box I and complete items B &C;.
<br /> . If not MOTOR OR VEHICLF"FLTI.1.;check the appropriate box in section.A and complete items I3 & D.
<br /> 11 Check the appropriate box.
<br /> C. Check the,type of MO*I'OR 131TICIA, FUEL(if box 1 is checked is A).
<br /> 1), Print the chemical nage of the:hazardous substance stared in the tank and the C:.A.S,#. (C".iienaical Abstract Service
<br /> number),if box1,is NOT checked in A..
<br /> Ili TANK OONSTRUC`1'10N-MARK ow rnim ONLY IN BOX A,I3,C&I)
<br /> 1.. Check only one item in TYPE OF SYSI"l M,TAN MA11121AL,3^v"I`F'RIOI2 LINING;and CORROSION 1'1CC)TEC. ON. '
<br /> 2, If C3'I'HER,print in the space provided.
<br /> PIPING, ITCF
<br /> 1. Circle A if above ground;circle U if underground' and circle both if applicable.
<br /> 2, If UN1CNC)"4rTN,circle.,or of(.3'l"Ft13I2,print in space provided.
<br /> 3. Indicate the LEAK I7I;17,C7110N system(s) used to comply with the monitoring requirement for the piping,
<br /> 1. Indicate the 1,1 A{Df,,'I°T.CW fION system()used to comply with the monitoring requirements for the tank.
<br /> 1. ESDI ,IF0 DA'I'I;LASS USM)-; C>ia'"j'4..1/y.. R(January,1.988 o' 191/tali).
<br /> 2. MIMATED QU "I'ITY of til7Ap:1 OUS SUBSTANCE remainingW€*p the tank(ire Gallons)..
<br /> 3. WAS TANK!FVLl,ED WFITI INE W17MATERIAL?Check'Yes'or'No .
<br /> APPI1CANrr MUSf SIGN AND DKFE 37111 FORM,AS I DIC'!t I19).
<br /> IP11?s'1` UC11O '1 113 L AGE N e IS
<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 jurisdictionnumbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. The facility number trust be the same as shown in form "l". 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 /> rr is°Tills mspohisiwxry o nffi,TA)CAL AGINCY MAT I IS EC"IN IME,FACILITY IYO V I? TIF"y'11111
<br /> ACCURACY 0111 1113 ITdI 1t. 710N. "111 LOCALAGINCY IS RESI'ONSIBIZ OR'11113 COMPLISPION OFTAE
<br /> AGENCY'US .ONLY* I "ITON BOX AND FOR FORWARDING ONE FOR 'A7 AND ASL A'.I )
<br /> FORM-B-(s)1-0 31117 17011,0WING ADDRESS.
<br /> SI-XIM WN113R, -, URC = , I-ROL BOARD
<br /> DATA PROCE&SING CENTFR
<br /> P.O.BOX 527
<br /> PARAMOUNI7,CA 9(M3
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