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INS47RUCIIONS FOR(DOMP1171ING 14*B1
<br /> GENERAL INSTRIJ(7110IN&
<br /> 1. tyre 1°'CIRM "B"shall be connoleted for each tank for all N1'. E ,PE'R 1`I'CIJANGE , RFMOVAIS and/or any
<br /> otherTANK INl ORIANNO C 11AN E,
<br /> 2 . This£orm should lie comp retcd by ei,her the PURMTpAPPLICAN717or the LOCALAGENCY U-NDERGROUISI)TANK
<br /> INC C`C) „
<br /> 1 nesse type or print clearly all requested infori >ation,
<br /> � . Uses, hard point w anti_2 v acs rare =,£=Eking 3 copies.
<br /> 'IOP OF FORK 'MARK ONLY ONE 11 I; '
<br /> 1, '41ar( an (X) in the box next to the €tcslt that hest descr€bds the reason' the form is being completed:
<br /> ,ta. I)BA or Facilhy .af.o xhese the tank is installed.
<br /> 1. TANK DESCRI19101d-Ct loll IZI11 A9.1„II.I I S-Il;Is -f;0 S-PI-i, "Ila'Y
<br /> A, lndicar ,tro°na°tom # r>a' lI` If t ierc, is a tank number that is used by his owner to idqnify the tank (cie AD70789).
<br /> Is, lec.,catc f.ae n arr,s .= the ,°ornpatiy lost, manafactur:d the tank (ex.ACNfI`sTANK 1!FG` ).
<br /> C. Indicate,,sic v rh,: [aiik was iia<aH d(ex 1987)
<br /> 11. Intt.
<br /> , .t<. ..r. :vl
<br /> , k c a1.t itS in fra'lons,(ex, `6,( or 10,W)etc.).
<br /> . i,
<br /> Il. °IANKCAt)Iva3;NCS
<br /> A. 1. 11.MOTOR VE11WILa,FUEL check boxx lead complete iterns 13& C.
<br /> If no,!, MOTOR R ,"I 11CLE p` t l,, ,that the appro reite box in section A and complete iterns B& D.
<br /> BCiic,,k ihe assn". 3 ar boy
<br /> C. i pc s srftICa C Iliat I t I'I 1 a (il't x t , c necked in 4j.
<br /> D. Pra,.2 ftc, cher,6c . .tame of the la„Fard us sabsianec stored in the tans:and the C,A,S.f#. (Chemical bstrac9 Service
<br /> b r if bras 116 NOT checked in,
<br /> 1IL TANK C:C) a9l`111r'('r10 --MARK ONE p11W ONLY IN WX A, Il,C&1)
<br /> J. Check onty one ;teras irs T YPE OF SS`1:`Z'F:M,"t"s4NK MrUL RIAL.,, INTERIOR UNING and CORROSION I'ItC)'E`E( T'IC)ti.
<br /> 2, If 011II:R,prim in fl e,space provided,
<br /> 1: rChcle A if ahc a.cstarad,circle 11 € underground;and circle both if applicable.
<br /> 1 If C. KNC a N ,s�� la.t it .f 111 1c grant in space provided.
<br /> 1 Indicate .h� LEAK
<br /> DE' EX 1,100, system(s) used if)cc-imply with the monitoring requirement for the piping-,
<br /> V. TANK LU.&K DITIVC1101a
<br /> 1, Indicate the ITAK I`€F H,C;l'RfN ey tern!.,)used to craa ply;with then monitoring re€luiretttents for the tank.
<br /> VI. IN`IsOPMV110fQ, ONTANK pili MANPAI'IAI`(1Sly)IN PLACT,
<br /> 1. 1.511SIt+° I'D I'3r'OF L A51 USED R OINTI-FI/YFA'R (January, 1998 or fJ`It'88)8
<br /> Z , .'t'ININI'l-D O AINxI FY of Is t:p.CsRDO S SUBSTANCE' remaining in the tank(in Gallons).
<br /> 3 tt,k.rg Tr NC La}!1,1:17 'ts"1 I II IIRT°.,kU e I°L .ICI I,R Check 'Yes' or°N()`.
<br /> ISI T IC "1`1 1x111'SIGN AND 19rVUE'1"I E FORM PI1S INDICNIED.
<br /> Ittl,51'IIC1C®IPIC71a1 1=O Ra'111B 1,00M, CaII C:III
<br /> The state underground sionne tank identification number is composed of the two digit county number, the three,di it jurisdiction.
<br /> number, the six digit awit, number and the six ditrit tank dumber, The county and jurisdiction numbers are predetermined and
<br /> car, be obtained by al rry the, State Ilcaard(916)739-2421. 1;' e facility nurnbcr must be the same as shown in farm"A". The
<br /> tank number sea;be ,llrl.7i:ed b 'the aaa.a€ agency: however, this number must be numerical and cannot contain,an`alphabet. It
<br /> the local al etscl.p rcfe ,the State 11c4 a,'d to assign the; tans;,number, please leave it blank
<br /> pI IS`L'IIII RF:SPONS� 'Ella°1'1119 1 )C° . CIh,N(' ' I' PF,("C °Ilii? ? Cd 1, "I'C) l�I ill?
<br /> C.C,'17 C Y C)Ir°I :INF `110N. ILR LOCAL AGENCY IS RESPONSIBIE FOR'111F C" IaL`11O € F 11111
<br /> 'L,C)(::iU-AGENCY I"iSIAONLY"INFORMA110N 13€1 ND Fll2 K)RWARDINO ONE FORM W XND A. C:IXI'L''ID
<br /> fulm-Pr(s) lrf),Iuv1 i 31,10WING r`ILf121t)i.WS.
<br /> I'AIEtlii`'is WOF C:r`li,lR)IZ IA
<br /> . JVI-I': LN LJ S ROL.WARD
<br /> C"/ S. rL l� .Sm
<br /> D.BOX 527
<br /> I$f#31ATsICS. $
<br /> NF,C A 90723
<br />
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