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S'YRTWNIC) S FOR C€iMT'T.I:?'ONG FO 'TP
<br />C: EP IC A , INSI' LrC.I O Ss
<br />1, Gime 1 t ,R-rf shall be, .ontpleted for each tank for all NTW, PERM11S, PURMrr C'I A GES, Rf G AINS and jos° <any
<br />other 77,ANK I IFOR-NI a°I°IC)N C ItAS Ofl,
<br />". I his foon should be cor f lctetl by eahc.r the 1')IIC i I` ApPI C A 1' or tate IA(` ., ACiII l Ns` C:18€)1.7P I1 IA
<br />3, Please or paha€ 6'carlv all requested s`ttf trn nt i n.
<br />I. UTsc a card poant .. 5 .n g nttrtnn,c nx , you are making 3 copies,'
<br />TOP lir FORM: *MAA C)CsLY ON t I I I3SP
<br />E S°Sank an, (:t') in the box newt to tfte hent that: best describes the reason the form is Ewing completed.
<br />2, tract€cau, the: D13A or facility name where the tank is installed.
<br />I. TANK DESCRIP110N - C OMPLT?°I"'_:l Ali, I"I I S - IF UNKNOWN - So SPEX'1T
<br />A. Indccal"e owners tank It) # m If there is a tank number that is used by the owner to identify the tank (ex. AI370789).
<br />B. Indicate^r, the name of the company that manufactured the tank (ex. ACM TANK MFG),
<br />C:;. indicate: the year the tank was installed (ex. 1987).
<br />. Indicate the hank capacity in gallons (ex. 25,000 or 10,000 ctc.).
<br />II. TANK (WI"IWIS
<br />A, I. If MOTOR VEJIIC.r,x. FUEL; L; € cck Iron. I and complete items B & Cr.
<br />2. If not MOTOR SI,FaIC ,T: 3 a F check the appropriate box in section A and complete items 13 1).
<br />. («.heck the appropriate box.
<br />'. Check the tyles of io'l-OR VE 'III( LE FUI.fI, (if box. I is checked in A).
<br />L). Print the chemical same of the hazardous substance stoned in the tank and the (,,A,S. . (Chemical Abstract Service
<br />number), if box 1 is Na r checked in A.
<br />TIS. SANK CON' - MARK ONE Ymm ONLY IN 1*,)X A, T3, C: & D
<br />1. Check only one stent i 3rYPE OF S)'SIlaM, ri%A iC IFRIAI , INIT.'ICIOR LINING and CC)RROSIOIN PRO't"I:C7110 .
<br />2. If OTHER, Irina in the ;space provided.
<br />V. PIPING 3 A" C)iq
<br />1, Circle A if above ground; e ircle T3 if underorremd; and circle both if applicable.
<br />2, If UNKNOWN. N. circle, or if f:)1111..1h , print its space provided.
<br />3. indicate the LiAK DI, I<C:l'l0N sustesr(s) used,tu comply with the monitoring requirement for the plpiog.
<br />V. TANK LEAK D1.51TU110N
<br />1. Indicate, the LEAK DE, i t'C"1'Ii')',N' systems) used to comply with the monitoring rcgDirements for the tank.
<br />VI.It RMN1"I0N ON TANK PERMANEN11M CLOSED IN PLACE
<br />1. F-511MATED DxVI`f LAST L S I) - MC)5?`nJ/'YFAR (January, 1.988 or 01/88).
<br />1 U1� 11 A111) CUA I`I`I'`r' of° II 7ARI) US SUITS"I'r N(,'is renfaining int the tank (in Gallons),
<br />3. WASTANK FILLEID WITH I: ERT MA11-TRIAL' Check '3'cs' or 'NO'.
<br />AiIpuC.tyt " ` MUSS" SIGN AND I' `17W FORM AS (A'I; ':I3.
<br />The state underground storage tank identification number is connpttsed of the two digit county number, the; three digit jurisdiction
<br />- mummer, the six digit facility number and the six digit lank numben The county and jurisdiction numbers are predetermined and
<br />earn be obtained by calling ,he State Board (916)n732-2421, The facility munber must be the same as shown in form "A". `ahe
<br />tank number may Fre assigned bre the Foetal agcncv; however, this number must be numerical and cannot contains an alphabet.. If
<br />the local agency prefers the Staie fyF)a d to a s Fgn the tank number, please leave it blank,
<br />IT IS `III"s. IlI'SW) SIIIUXI"Y OF'17 LW AL AGENCY111AT I S'IN71 TTI ? FAC 11,Y TO WIRI ' ` 1I I
<br />PsC CU C OF 7.7111 ? I IrCITiI A'OON. '1141" f.rC2C'AL AGENCY IS PO SII I Is FOR ' 11TT C'C)AalPLE-110OF 77117,
<br />'LOCAL AGENCY USE ONLY' ITsI:FOR A' 707 13K)X AND FOR I II A DING ONE FORM iA W R W AND AW)C.°I IED
<br />I' 1C TO 114IK It`t`bl<l<Cl srING ?CI)IIICN s,
<br />MA11lOF C'AI,IFOR IA
<br />C:`/() 5..:, f C F;f F.S.
<br />I) "I'A P1200L:SSIIC 3 C"I ;Igl's.II
<br />1'.C), WX 527
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