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INS 1`RU . O »FOR COMPIHnNCY FORM`t3" <br /> GEMIRAL N r TSU T 1€) e <br /> L One FO "I3"shall be completed for each tank for all NEW-PERMr.11S,PERMIT CHANG&S, TtI MOVAT and/or any <br /> other TANK I I Tt 1 ON CAIIANG " <br /> 2. This form should be completed by either the'P1,1 T APPLICAmr or the LOCAL AG13NCY UNDERGROUND'I'ANK <br /> INSPECTOR. <br /> 3. Please type orrint clean all requested information. <br /> p Y <br /> 4. Use a hard point writing instrument,you are making 3 copies.; <br /> TOP OF FORM.'MARK ONLY ONE TP[W" <br /> 1. Mark an in,the box next to the item that best describes the reason the Toros is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I, 'TANTO T)I- R €N-COMPIa ALL rFEMS-IIx;,UNKNOWNa <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 MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex,25,000 or 10,000 etc.). <br /> H. TANK COMTiNTS <br /> A. L If MOTOR VEHICLF,,FUEL,check box i and complete items II&C. <br /> 2. If not MOTOR VEHICLE LE;F UE L,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 1 is checked in A). <br /> D. 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 /> HL TANK C O U 'I€T IC ONP TIFM ONLY IN BOX A,Ism C&1a <br /> 1. Check only one item in TYPE€7I'Sl STEM,I`A K MATERIAL,IMI'ERIOR LINING and CORROSION PRO'IT:t'°I'I€N. <br /> 2. If CT ER,print in the space provided. <br /> IV. PIPING INFORMA110N <br /> 1. Circle A if above ground;circle TJ if underground,and circle both if applicable. ` <br /> 2. If UNKNOWN,circle, or if OTHER,print in space provided, <br /> 3: Indicate the LEAK I EITI "I'l€BPmi system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LPAK DI-I 111 <br /> 1, Indicate the LEAK DFi`I'f €yN system(s)used to comply with the monitoring requirements for the task: <br /> Y <br /> STI. INFORMATION ONTANK PHRMANEPXT. Y C[ -0 IN PLACE <br /> 1, IIMNIT-�D DATE I..AST USED-MOI FII/T'T:`AR(January, 1988 or 01/88). <br /> . ESTIMATED€UANTITY of IIA .AI2I3OUS SUBS`rANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WPI`€i INEXl'MATT IAL?Check'Yes'or'[DC7', <br /> —APPLICANT I.1 SIGN ANT)D IE'I1 a FORM AS T 17ICT ?. <br /> lNgrRUCIION FOR'"1TIE €:AL,AGE =S <br /> The state underground storage tank idcntifs`eafion number is composed of the two digit county number,th"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' e <br /> tank number may be assigned by the local agency;however,this number roust 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 T1Tf? ON',%3 'CITE 71W IMAL AGENCY 71 IAT I SPWI THE FACHM 11111 <br /> ACCURAC Y OF`T'III:?IIS TI 'ITON. '171 I. 1.AGENCY IS RESPONSIBLE FOR111E C O PIHIIO 0171TIE <br /> *LOCAL AGENCY USE ONLY'INFORMA110N BOX AND FOR FORWA RDING,ONE IIORM'A*AND ASSOCIATED <br /> TC `W(s)TO 11111 Trt'11,0 ING ADDRIM <br /> C/o S. a T?T$ a <br /> E.O.�g ��gXO�5pp27 <br />