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44"
<br /> a'ys1I11 C"M1lCt t (XIMP1..II1'I Ca I
<br /> i. One I. RI 13'shall be cc,"ni leted for each tank for all NEW 1"> I' ,PERMH CII NCIi-, IC1?.:1C) , I and/or any
<br /> oth r T.,,%N 1N CRMXI10N C'IL CH"l-
<br /> `I`hiis forn,an'ould be completed by either the PPR rr 11PU.CA'KI'or the LOCAL AGENCY UNDERGROUNDTANK
<br /> ie-as ,-Pr or brim clearly all,requested information,
<br /> ,,.ate. Ise a ha!(Lp rjhttwetting iratturnew,J#m are inaWing 3 c« ins, e
<br /> TOP 6F FOAM:-MARK ONLY UNJUM-EW
<br /> .t', , an M)fir till l�owtt xt to the item that best describes the reason the framer is be`int completed,
<br /> IndicatetheI)BA or I sc°ility seem where the tam is installed.
<br /> "° e
<br /> L TAN I)I;-SC;RIRLI I-C"yI TIT1 1 AIJ,L1` -IF UNKNOWN-ISO 1'SM-7117Y
<br /> :, Ind,c<at.".",owners tank 11)# - If there is a tank number that is used by the owner to identify the lath.(ex.AB70789).
<br /> 13. inijealc hire name of ike company that manufactured the task(ex.AC IME',`TANK :MFG.),
<br /> C. Cndic:ate the year the tank was installed(ex.1987).
<br /> L'a, indicate the tank capacity in grallons(ex.25,000 or 10,000 etc.).
<br /> 11. 'I"r4NK MNI°1:` I I
<br /> A. 3, if mO'rOR 4E1 C 1:;FUEL,check box 1 and complete iterns 11&C,
<br /> 2, If not Mt)'I'0R'4'EIllCLE 3 t;I 1_,.check the appropriate box in section A and complete items 11 & 1).
<br /> ,R ('heck the. appropriate box.
<br /> i`. (,'beck the type of MOTORMOTORE'llICI:1,FUEL
<br /> L(€f box 1 is checked in A).
<br /> 1), print utas chcrnical name ofthe, h-a:=ardous subsiance stored in the tank and the C'.A.S. _(Chemical abstract Service
<br /> lit. TANK C ONS-17RIIr..',I £)t -:n It.1;oNi3 rrum oNLY IN BOX ti:,13,C:&1)
<br /> Check ca+ily one item an .l")PE t)I" x t t> ,'", A1C. r1':["]iT2t 4l, I:�TT"RIOR LINING and CORROSION [�RUI"1sC"['[t:3"3.
<br /> 2. 1 C)"1'I 11TI;priest: cr ,psacc prr3 idc t.
<br /> . PIPING INFORMN110N
<br /> 1- C ircie A if above gyrrrac nd;circle U if underground, and circle bath if applicable.
<br /> 2, If UNKNOWN, circle: or if"£)T`HE*R,print in space provided.
<br /> :3. Indicate the 1.€AK I)3,'1diC.-1 ON, systern(s)used to comply wilb the monitornig'4eiquirnrnent for the piping.
<br /> V. TANK LUAK 1)1f1'1 "I1C)l
<br /> 1. Indicate the l.iVkK I)I..l KN'TON tester (s) used to comply with the monitoring requirements for the tank,
<br /> 1. INFORa 3"1"1ON ONTANK P1.1ZMAN17.911M CLOSED IN PL t'1?
<br /> 1. h: 1'I 11rA'fl.l) ).111\11 `°I`USED-SIO 17JI/Y R(January, 1.988 or 01/88), .
<br /> 2, is l Iy NI" l)QUAI)sTIPe of IIAZARt)l:)1'S SUBSIANCE remaining in the tank.(in Gallons).
<br /> .. WASTANK FILLEI) WITH INE.I,'1';x. 'AIAL? ("beck'Yes'or'No'
<br /> aP1'1,IcA,N r rusr SIGN AND I)N111111 1 FORM AS I It ``1:<I).
<br /> INS L"RCI(tt"I N FOR"11111 LOCAL AGEN0US
<br /> The state underground storage tank ideistification number is composed of the two digit county number,the three digit jurisdiction '
<br /> n arnber, the six digit facility number and the sic€3ih,t bra nc:sabM The county and jurisdiction numbers are predetermined and
<br /> Can be obtained by calling tat.Slat€ Board (9'16)739-2421, The facility cumber roust be the same as shown in form W. The
<br /> tank lin stbe.r may b,, assigned:d by the local a, n yo. Ir,€.arra,°vc.r,this numbermust be: numerical and cannot contain an alphabet. If
<br /> t
<br /> the 1 al agency Prefers Ole,Stxte lwr3ard aa,assil,n the task number,please leave it blank.
<br /> 1'IS I IE RE,5P oa,NSII1IIXI" 01..1' E LOCAL r"CC.313 C 11 AT INSPECTS 11111 F C:FIYIN TO WIRIFY1111f
<br /> ACCURACY Y C)1r'11111 I FOR.,. 'I"ION. '111131.C)C'a1,AGENCY 1S R ISPO SI Im1s FOR111E C°OMPI I ITON 017'1`1 11
<br /> ILOC L A-CiENCY USIT ONLY'INFORMMICINIM AND MR 1fORWA DING,ONE MRM W D A%OCIX1ED
<br /> S'I' E OF(W.11k)RNIA
<br /> SI tri E WNIER RIEWURCMS CONTROL BOARD
<br /> DMA PROCI.MSING(MMI CR
<br /> P0BOX 5Z7
<br /> Palial C)C;NI',CIA f 1
<br />
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