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IN917RUMONS MR COMPLITIING 'Ir
<br /> tSTNli2fi,t,IN "RIIC 'IC)T�ISr
<br /> 1. One l'CIRM"I3"shall be completed for each tank for all MEW PFRMMS,PERM17FCHANGE4 and/tar any
<br /> either T NK INFORMATION CTIANGE.
<br /> 2. `This form should be completed by either theEI'I P C'.r1 L or the LOCAL AGENCY UN ?RCIi O]UNi)TANEL
<br /> INSPECI` R,
<br /> 3. Please tyke or print clearly all requested information.
<br /> 4, Use a hard point writing instrument,you are making 3 copies.
<br /> I Of'FORM. 'MARK ONIM ONE rriffm,
<br /> 1, Markair (X) in the box next to the itemthatBest escribcx tht-reason the form is being completed.
<br /> 2. Indicate the.DB),or l"acility nanle where the tank is Installed.
<br /> I. TANK }T :E I "TON-- =w) I'J VI`I; I L]G II S -LIQ U OWN S4 S Iiz I e
<br /> A. Indicate �,kce e bw l) ,-If thele is a tank number that is used by the towner to�de.ntify'the tank(er,AI370789).
<br /> , Indicate. the .narne of the:company that manufactured the tank(ex,A MI3'I"ANTC MFG,).
<br /> C, Indicate the year the tank was installed (ex, 1987).
<br /> I), Indicate the tatcapacity in gallons(ex, ,�or 10,
<br /> s, etc,).
<br /> H. TANK MMENIS
<br /> S
<br /> A, 1. If MOTOR iv`LIll I,f FUEL, check box I and cornpletc items B &
<br /> 2.If not MOTOR V1;11ICLIi l+`A.1L.,check the appropriate box in section A and complete items IT So D.
<br /> B. Check the:appropriate box.
<br /> C, Check the type of�1t O OR VEHICLE FUST.(if box l is checked in A).
<br /> I), Print the chernical name of the hazardous substance stored in the tank and the C,A,S, , (Chemical Abstract Semice
<br /> number), if box 1 is NOT checked in A.
<br /> Ili. TANK CONS'rRU('I.TON-MARK ONE MEM ONLY IN BOX A,1,C&I)
<br /> 1.. Check only one item in"ryl'Ei C)Ia SYS"I'E 'PANIC MATERIAL, IMERIOR LINING and CORROSION IaltC9"C E(7110 .
<br /> ``2: If OTHER,print is the space provided,
<br /> I
<br /> IV. PIPYNG INMRMAMON
<br /> I, Circle !s if alcove groaa d; circle C.1 if underground;and circle both if applicable.
<br /> 1 If UNKNOWN,N,cracle;or if O'I7IFR,print in space provided,
<br /> 3. Indicate the LL,,K T)E F:C'FIO system(s) used to comply with the monitoring;requirement for the.Taiping,
<br /> V. TANK IIAK DITIVtMO
<br /> I.. Indicate the LF/%K Ali T I;(°I"f }'S systesns-
<br /> ( used to comply with the monitoring requirements for the tank.
<br /> VT. INIX)RMMION C)N T NX i'ERMANEN"I"I C10SI D IN T'LA I?
<br /> 1, ES`I`I'MATED 3AT . sr L y;['.I)- 43 I"LI/YEAR(January,1988 or 41/fltt);'
<br /> 2. J";STI ATI I) QI.AN`1 Y of HAZARDOUS SUBS t`ANC remaining in the tank(in Gallons).
<br /> 3. WASTANK FILLED th'II'LIINT-`,,KI' A ERTAL?("heck'Yes' or'NO'.
<br /> APPLIC' I`MIJIFSIGN AND I3A 111 1 M]VORM AS INDIUMID.
<br /> IMIT17RUCITON FO `I°IM LOCAL e'GENC IE-S
<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 anchthe 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 assi.aned 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 lease it blank,
<br /> MIS TIM R&S NII I]XIT OF TITE LO(AL AGIMSICY L'IIXi"INIs'i'E(`I S"I III Ip CdILX.. "I'C)VERIFY ME
<br /> ACCURACY CTIA 17111 INFORmA,nord. 'I'IIL?uXAL AGENCY IS RIISPONSIBLE FOR 17111 COMP1ZnON 0I71II1:
<br /> "l . ,AGENCY USF ONLY'INFORMNnON BOX AND FOR YuR ARDING ONli FORM*A"AM A&S -Nn!D
<br /> 91'A171=OF CA11FORNIA
<br /> /ca swap- s.
<br /> P.O.BOX S27
<br /> P OUNI°,CA 90723
<br />
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