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INS TCI.JC:ITONS FOR CO P1131TNG " ffi <br /> GENERAL U ON <br /> 1. One FORM"E3"shall be completed for each tank for all NEW PERMITS,PEMMIT C">IIAN(A S, R17MOVALS and/or any <br /> other TANK IN TION CHANGE <br /> 2. This form should be completed by either the PERMY.r APPLICANT or the I.AWAL AGENCY UNDE?II.C'sICOUND TANK <br /> INSPECrOIL <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a.hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:WARK ONLY,ONE MINI* <br /> 1. Mark an (7{)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 /> I. TANK,D: ,I2 I O IyTHIL?,All,TIM -IF UNKNOWN-SO SI'I? , rY <br /> A. Indicate owners tank ID #- If there is a tank number that is used by the owner to identify the tank.(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MI'Y:i.), <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 1Q, .etc.): <br /> II. TANK CON17FXI',S <br /> A. 1. If MOTOR VEHICLE IT;EL,check box I and complete items B &C. <br /> 2. If not MOTOR VEHICLE FUI;I„check the appropriate box in section A and complete items B &D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). <br /> I). 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 /> M. TANK C;ON,1 IJCt71ON-MARK ONE ITEM ONLY IN BOXA,I3,C:& D <br /> I. Check only one item:in TYPE Of'SYS"IU- ,TANK MATERIAL,INTEIIIOR LINING and CORROSION I'FZC)TEC"I10N. <br /> 2. If OTHER,print in the space provided. <br /> PIPING I 'nON <br /> 1. Circle.A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,N,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DFITC'I70N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DIE' CIN <br /> 1. Indicate the LEAK DE'IECI70N system(s)used to comply with the monitoring requirements for the tank. <br /> . 'C9. A ON ONTANK PERMANTWIlM CIDSED IN PIACE <br /> 1. ES13MATED DATE LAST USED-IAC:) I/YIF,AR(January,1988 or 01/88). <br /> 2. ESTIMATED TE'D QUANTITY of HAZARDOUS SUBS-I°EIO C",E remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFITI I;NEICT TERhM,7 Check'Yes'or'NO'. <br /> APPIlcAmr MUST SIGN AND EDXIEE `ERIE?FO )ICA31M, <br /> UMRUCITON FOR 11IF LOCAL AGUNCIES <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 /> IT IS 111E RESPONSIBII.1717Y OF 717.11 LOCAL ACI CY'I'IXF INSPEZI.N 1III3 FACIILT17Y TO VERTFYTIIE <br /> ACCURACY tJtF THE INFORMA'110N. TEII?LOCAL AGENCY IS RESPONSIBLE-IrOit TIIE C;OMPLHI'ION OlkT1113 <br /> "LOCAL AGENCY USE ONLY'INFORMKIION BOX AND FOR 11ORWARDING ONE FORM'A" D AS.S(XT I7 1) <br /> FORM"II"(s)TO 31IE FOI1,0WING ADDRESS. <br /> ATE OF CALIFORNIA <br /> Sr)VrF WATE R I? ITR(MS C:ONI'ROI..130ARD <br /> C/o S. :I:?ii p S. <br /> P.O.BOX 523 <br /> PARAMOUNT,CA 90723 <br /> �- v <br />