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GEWERAL INi C?CI`(AW, _
<br /> ,. One I°OR\3,I"I3'shall be completed for each tank,for all NIV. PERM1171N, PE EMU CHANGIIREMOVAIS and/or any
<br /> other'I'ANK INFORMA7110N CHANGE
<br /> 1 'I'his Torr a shou!d be completed by either the PEPmrr AI C',A F or the LOCAL AGENCY UNDURGROUND'I'ANK
<br /> 11fSI EC'I'()II
<br /> 3. Please type or print clearly all requested information.
<br /> 4Use a hard piunt twit ug instrurrie-A,you are making 3 copies.
<br /> 4
<br /> TOP OF 17R— WARONLY ONE Ella
<br /> . Mark an (X) its the box next to the item that best describes the reason the form is being;completed.
<br /> 2. Indicate the DBA or Facility=ntarne where the tank is installed.
<br /> I_ 'BANK I I?. P IIVI;`O - IA tI,III II ALL I°I3 n, S-IIs L.7 'C; t - CI,SPLIC
<br /> A. Indicate owners tams 12#- If ti,ere is a tank number that is used by the owner to identity the tank(ex.tAB74759).
<br /> 13, loth to the mane ofthc ompany that manufactured the tank (ex.ACAI "I'ANK MFG,),
<br /> C;. Indicate the yca, tate to n&was anstalle l(cx. 1987).
<br /> I). Indli at zi e tank capawic3 in gallon.(ex, 2S,(N0l or 10,000 etc.).
<br /> I. 7`A1 CC3 IF?�daS
<br /> A, 1. if M01'01Z VF111 E,t" FUEL,check box 1 and complete items B&C.
<br /> 2. If not MOTOR VI LII S.E' JUEI,check the appropriate box in section A and complete items 13& D.
<br /> B. (,hear that appropriate box,.
<br /> C;. C beck the type of:-I('YI'O '.f1ls E I p'l I t,(if box is checked in<A).
<br /> E). Print the chemical name of the hazardous substance shored in the tank and-the C.A.S. .(Chemical Abstract Scmice
<br /> nurnber), if box I is N 'E checked in
<br /> III. '$:ANS(ONSI'RUC-I ION--MARK ONE.'rITM ONLY IN BOX A,Is,C& ?
<br /> 1. Check-only one item in TYPE (A, SA' S'E vt."SF�tilz GItA"I'ERIAI.,, II�pERIO LINING and CORROSION I'RO'yE('n 3`sl.
<br /> 2. If f 1,111y1�'.,prbnt in thu snace provided.
<br /> 1. Cirde A if above ground;circle if underground;and circle bath if applicable:
<br /> 2, If t !'al ,` OWN circle, or if 0EI1s print in space provided,3. Indicate the LEAK system(S) used to comply with the monitoring requirement for the piping.
<br /> V. 'FAN .I:AIC Iyll'ITX7II II
<br /> 1.. Indicate the LFAK t `l FCTI0N slstern(s) used to comply with the monitoring requirements for the tank.
<br /> VI, INCs'O A1101d CIN TANK I'ER EN111,'Y CLOSE-31[i IN PI AC E
<br /> a. 1 sum.A-l`is`t) Qu AN'B'FY of HAZARDOUS (NCE r(, a c r Qt��Bt
<br /> 1. lrtS l`I�ttA II?Iy t5 A l`I=I.AS'p I;TSI?lI
<br /> 'SL�3S"I`A�IC�remainin�;s the tank (in Gallons),
<br /> 3. WAS`['.A.NIC..I'lUE D Wl'I'1I INERT JMA"I'E RI;AI,` f'heck'Yes'orN, O'.
<br /> AI P11 ' "I' I M'SICII AIT DA'[ r'III FORM AS INMICNIED,
<br /> INSIRLJ(TFION IaU UII3 LOCAL AGENCIES
<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 fatuity number and the six dilat tank number, The county`and jurisdiction numbers are predetermined and
<br /> can be obtained by;a',,ng the;hate Boa (916)739-2421. "'hc facility number must be the same as shown in Form"A", 'I'he
<br /> tank number may be assigaied by the local agency; however, this number must be numerical and cannot contain an alphabet. If
<br /> the Jeal agencyprefers the State Board to assign the tank number,please leave it blank.
<br /> 171 irS'PI E RUSPONSIBlIXIN OF THE L0(:AL T ACSI Y 3 IA"I° It'1 i"I FI? AC 1 'ft)VERIFY IIIE
<br /> ACC(:I I -('Y OF 1111"IIS FO AI'IC1M `11IR LOCAL,ACmENC'Y"IS RESPONSIBLE FOR71111. COMPIET]JON t F 111E
<br /> 'I :AI.,AGENCY USE(IDLY'INIaORMA`FT0N BOX AND IXIR A DI (I ONE FORM W AND ASNOCINIED
<br /> I'A'II;
<br /> OF C'�AAI.FCyl NIA
<br /> E°AJE A'II?II ICI.SCSI.ROES CONTROL BOARD
<br /> C/O
<br /> DA"T"A PROCESSING CIWI"F
<br /> RO.BOX 527
<br /> P UA OUN"I,CA 90723
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