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IN,'V1`RUCI10NS FSR COMPLETING FORM"II" <br /> GENERAL INSTRUC11ONS- <br /> 1. One FORM"Lt"shall be completed for each lank for all NFW PFRMrPS,,PERMIT C7 C1 F'S, RE OVAI S and/or any <br /> other TANK INFORMA'11ON CHANGE <br /> G <br /> 2. This form should be completed by either the PERVIT APPLI<< 1'or the IDCAL AGENCY UNDERGROUNDTANK <br /> SPEC R <br /> x TMt 3. Please type or print clearly all requested information. <br /> ,Ise a hard point writing,instrument,;you are ding 3co es. <br /> TOP OF FORM."MARK ONLY ONE ITIN" <br /> 1. mark anm( )in the,box next:to the item that-best describes the reason the formis bcing: ompleted. <br /> 1 Indicate the DBA or Facility naive where the tank is installed; <br /> 1. TANK F31- 1C)N-COMP11 qU ALL ITEMS-IF UNKNOWN <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 /> F3. Indicate the name bf the courpany that manufactured the tants(ex.ACME TANK 1i FG.). <br /> C. Indicate the year the tank was installed (ex.1987). <br /> D. Indicate the tank capacity in gallons(ex.25; or 10,000 etc,). <br /> i, TANK CONWNI'S <br /> A. 1,If MOTOR VFHICLF FUEL,check box I and complete items II&C. <br /> 2. If not MOTOR VEMICLE FUEL,check the appropriate box in sections A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MO` (BIZ VEHICLE FUEL(if box'I is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the task and the C,A.S. .(Chemical Abstract'Service <br /> number),if box 1 is NOT checked in A. <br /> 111, TANK C:C) I U '100-MARK ow nvm omx IN Box A,13,Cr&13 <br /> L Check only one item in TYPE OfSVSFEM,TANK MATERIAL.,INTERIOR LINING and CORROSION F RO'I'I'C'1ION. <br /> 2. If OTHER,paint in the space provided. <br /> IV. PIPING INFORMA11ON <br /> 1. Circle A if above ground;circle U if underground,and circle both if applicable, <br /> 2. If UNKNOWN,circle, or if 0'111 29 print in space provided: <br /> 3. Indicate the LEAK DE,'JECTION systesn(s)'used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK I3FF1 I'IO <br /> L Indicate the LEAK DEI'I , ON system(s)used to comply with the monitoring requirements for the tank. <br /> . INIZORMATION ONTANK PER ANENEI. (1,0SE0 IN PIACE <br /> 1. ES'FIMATED DATE I.AS'I'USED« ON`III/YEAR(January, I'M or 01/88): <br /> 2. ESTIMATED OLIANTITY of IfAI.ARI3t.US SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TALE{FILLED W I INER"r MATERIAL?Check'Yes'or'NO'. <br /> APPLHAW MUST SIGN AND D IE 11111: R AS INDICAIED. < <br /> INSIMUCHON FORTIIE LOCAL AGI.. C a 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 and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board 0)16)739-2421, Tlic facility number must be the same as shown in form "A". ne <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 hoard to assign the tank number,please leave it blank. <br /> rF IS THE RESPONSIBHXI'Y014-1-1111 IMAL AGENCY 3'11AT IN SPEC IS 711?FACILrily TO VERIFY 11111E <br /> ACCURACY OF THE INIAOR "I10N. 171E LOCAL AL AGI NCIS-RE%TONSIBLE FOR TIIE(X) PLIIIION OF°17113 <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR IK)R A SING ONE F R "A"AND AS" 1131) <br /> 143R -W(s)TO TIIE M1.1,0WING ADDR1 . <br /> STKIM OF CA11FORNIA <br /> STA'I'R [Tilk RESOURCES CONTROL OLBOARD <br /> /o Sew E.Ps. <br /> DtarA PROCM&SING .NI`E <br /> P.O.BOX 527 <br /> PARAMOUNT,CN 90723, <br />