|
INS''RUC 11ONS FOR COMPL i NCI I -B-
<br /> G INFR L 1NS I]o,LlC.$C(:1N s:
<br /> L One I'f3RM"13"shall be completed for each mink for all NP9 PERMTIN,Pf.,RMrr CHANGES, REMOVATIS and/or any
<br /> otherTANK INC LION CHANGE
<br /> 2. This form should be completed by ei€her the BL".R1' PP11C 'or the LOCAL L.r GENC UNDERGROUNI)TANK
<br /> INSPIXTOR.
<br /> 31 please type or print clearly all requested information.
<br /> d. Use a hard point writing fristremienit Iota are making 3 copies.
<br /> TOP 014 PORM, 'MARK NT°E C)NP LI "
<br /> 1, Mark an (X) in tit,. ho.,next to the itcrrt that nest describes the reasohr lac foram is being completed.
<br /> 2, lndicam the DBA or facal 91 raiisu where the Sauk is mslallcd,
<br /> I. TANK T)I1SC ;IP110N--i CI9ibIPI.,L1`E All,:1`11Y S.. IF UNKNOWN s-SO SPECIFY
<br /> A, Indicate nvot€es lailk 1:1;) If iltere is a tank number that is used by the owner to identify the tank(ex,t B707 9).
<br /> 3, Indicate the nan e <,€`!'he a.ompany thtat, manufactured the tank(ex.ACMETANK",'tNK? F G).
<br /> C. Indicate ftsc yca. .,i- tcm,' vru snstalltoj (ex. 1957).
<br /> I). Indicate tht t'zra c 'patcit:y in gallons (ex.25,000 or I0.000 crc.).
<br /> IL. TANK C1C>IV"I?N.
<br /> A, 1 If%IOI O y ISIC r_I FUE11,check box 1 and complete items Il & (1
<br /> , If iv)t MOTOR g I-'HI LF FUF. L,chef k the appropriate boxin section A and complete items IT& D,
<br /> B. Clic ek the nnpr<p .,ate:box.
<br /> C. a r s.k the tam Nt 1,O Z V17111 f a FUEL(if box I is checked in,y).
<br /> 1), Print the cInc tnuil ;wnc of the, haeardous substance st€>ro(l in the tank and the C,A,S . (Chemical Abstract Service
<br /> r kniber),it box 11 i- NOT check-ed in A,
<br /> 11L TANK CC)NfL3"RUC310ol,- A ONE NIN ONLY IN 1X)X A, II,C
<br /> 1, 1''beck only sire. item, in'!-PE,C?I SYSTEM, LANK MATERIAL, INTERIOR LINING and CORROSION I'ItC)`IT,C 1'10'/
<br /> Ia(7'1II T sprint in tee space prce k,,d,
<br /> IV. PIPING ISIM)IIM) I'I£1N
<br /> 1. Circle A if aboi r ground circle U if underground; and circle both if applicable,
<br /> 2 If UNKNOWN, circle,,, or€° i'TJI IC print in space provided,
<br /> 3_ Indicate tax LE-,NS used to compiy with the monitoring requirement for the piping.
<br /> V. `T`ANIC.IXAK 1)ITI`X11ON
<br /> 1, Indicate the Ll-,'AK Il'I7I1'.a°']Cr N s}"I'teaxi(s) used to comply with the monitoring requirements, for the tank.
<br /> V1. INIOItMA11tl3N ON T NIC PERMANHUN"FIX CLOSED I IN PL C33
<br /> 1. ESTIMATED I)ND"LAS LSI La a 141N111,fLI,ILIC(January, 1988 or 01f8S).
<br /> 2. a, 1`M Ill) QUTANTI'l'i of HAZARDO 'S SLTI3SIANCIi,z-ersaining in the t=ank(in Gallons),
<br /> 3, VVAS ,,st N° FILLET) a%a%I'I"ll INER'I'MtI'IERIAL?("heck"Ycs'€ar'NO%
<br /> FSE"1AIC I"ILLI I' I(aN SNL)Illi"I'I<°YTr R)RM F d INDICNI I0,
<br /> IN 1' UOTIC)N FO °IFIL? 1, L AGErN>"I
<br /> The state:underground storage bank identificaatioh number is composed of the two digit county number, the Hasse digit jurisdiction
<br /> number, the six digit facility number and the six digit tank number. 'I'he county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (9I6)739-2421.. The facility number must be the same as shown in form"R".
<br /> tank number may be.a ligated 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 /> LI 1S®3�7 NBf) I �LIa1"I C)Er I1 T C) L C� 3NC"I I .I`1NS1�I 3 `i[I fa c pI "ICI .3I2Iu, E
<br /> C f IANC C3Ii LIN .I Il Na °I) 1 ( I< ('TEN( I s CE?SPON SIII FOR IIIE OMPII `€ON OFr"I`F I�3
<br /> 'IX)CA.I.AGENCYIIS NLY'INFORMA 10N I X AND FOR FORWARDING ON14 FORM'A"AND AW)CINIED
<br /> FORM, "II"(s)TO`1'l1II M)11-OWING z DDRI.S&
<br /> 5FiYOI 017 CALIFORNIA
<br /> T`,d'IZL WNYER RFSOURCESIr )
<br /> /o S: ':I?I?FE'S
<br /> DXEA PROCaSSING CTI`I<
<br /> P,0, BOX 527
<br />
|