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IN,%'MUC'nONS FOR COMPIEPING,IU `B <br /> GINERAL INSIMUCTION& <br /> L One I^'CJRM"B"shalt be completed for each,tank for allNFW 1 ,PERMIT CIIANGES, MING VAI. and/or any' <br /> other TANK INTI 31ON(3LANG <br /> 2: This forth should be completed by either the 6"II 1`I ILLI I'or the LOCAL AGE UNDERGROUND" ANK <br /> INSPECIUR. <br /> r 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument.,you,are leaking 3 copies, <br /> TOP OF FORM."MARK ONLY ONE 1`11W <br /> 1. Mark an ( )In the box next to the item that best describes the reason the forret iio, eing c.. pleted. <br /> 2. Indicate the T313A or Facility name where the tank is installed. <br /> . TANK DESCRIPTION MPT 'g ALL .. : S-1P UNKNOWN-SO SPWFy Indicate owners tank ID# -If there is a tank number that is used by theowner to identify the tank(ex.AIB70789). <br /> B. Indicate the name of the company that manufactured th6 tank(ex.ACME,TANK FG.). <br /> C. Indicate the year the tank was installed(ex.1987). <br /> D. Indicate the tank capacity in gallons(ex.25j000 or 10,000 etc.). <br /> 11. TANK COMPENTS <br /> A� 1.If Mt)'I'OR VFlIICLE FCJFL,check box 1 and complete nerals B&C. <br /> 2. If not MOTOR V IIIf LE. FUEL,L,,check the appropriate box in section A and complete iters EB b'c D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box l is checked in A). <br /> D. Print the chemical name of the hazardous substance stirred in the tank and the C;;.A.S. .(Chemical Abstract Service <br /> number),if box I is NOT checked in A. <br /> lit. TANK C:t) TUC 1ON-MARK ONE TFFM ONLY IN BOX A,K Cw&D <br /> 1. Check only one item in TYPE 01�SYS"IV ,TANK IMN17FRIAL, ITNI' I21CBR LINING and CORROSION PRUIT(TI10N. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMAMON <br /> 1. Circle A if above ground;circle U if underground,and circle bath if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIE'I&print in space prodded. <br /> 3. Indicate the LEAK BE TE , .ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK 1)1?"•. 1TC)N <br /> L Indicate the LEAK DL-l-ECI10N system(s)used to comply with the monitoring requirements for the tank: <br /> VL. INVORMATION ON TANK PERMANLWI1,Y C S 9)IN PLACE <br /> 1. I3 DATE IlkS'1'USFD- OINTITI/Y11AR(January, 1988 or 01/88): <br /> 2. F-STIMATED OUA `I'I'I'of ILA7.ARI)OUS SURSF'ANC E remaining in the tank(in Gallons): <br /> 1 WAS TANK FILLED I'I`FI INE RT SIA ,RIAL?Check'Yes'or'C CF', <br /> APPLICAN17 MUST SIGN AND A~I 111T FORM AS INDIC ). <br /> 91T2IT O THE „AGENCIES, w,.. <br /> 'l,he state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction <br /> number,the silo 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 force "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 Berard to assign the tank number,please leave it blank: <br /> IT IST 'C)NSIB L OF°l HE IMAL AGENCY THAT I SPECIS THE FA 117Y °[Tit? <br /> ACC:I3 CC:`Y OF TTI?INIU IION. "II I.,() I.ACF1; tIY°IS NSIIII.13 'l II C.C) P1 VI ON O1z°1"6113 <br /> "I I.AGENCY USE ONI.V INFORMK110N BOX AND FOR FORWARDING ONE FOR "A"AND ASSOCIA71ED' <br /> FORM-Ir(s)T°()17113,F011,0WING ADDRESS. <br /> SFNrF OF CAIJIURNIA <br /> =STATT:Q NIT,-R R07SOURCES CONIMOL BOARD <br /> DATA PR z SING C I IE <br /> P.O.BOX SZ7. <br /> PA tai MOU , ,CA, <br /> x <br /> t <br />