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CFF,F ILIIAL INSTRUC)ION&
<br />L One FO II` shall e con-plet :l for each fank few aall NEW FII F [ , I*ERMrI` ('IIA C1IFSg EMO AI -S and/or any
<br />other T N INII)RIVid:'17If: & €- lA:rit11T
<br />2. `]'leis form should be ccssaapleied by either the. 1'; II' AP LI(:.A 'F or the LOCAL AGENCY UNDIPRG2€2UD A
<br />2. Please .type or Pon c "'C arb, all tnforn aa; an.
<br />4, Use ea bend point, wr14as `.r nstr n-nent, you are :na akan2 3 copies.
<br />)1r 017 I )RM- 'MASK ONLY ONE HUM,"
<br />1, Markan n ( ) in t1u, box next to the stent that best describes tire reason the form is tieing eomplt ted.
<br />2. Indacatc elte EMA or Facility name where the tank is installed.
<br />1. TAN ECSC 11`110 - C €)MIR1, 17t All, r rC; - llla UNKNOWN - So3 SPIEC FT
<br />A. Indicate owners tank If) # - If there is a tank cumber Haat is used by the crwner to identify the tank (ex. AB70789).
<br />Ti. Indicate the sea€vte: of the company that manufactured the tattle. (ex. AC;;ar E ANN MFG).
<br />C. Indicate the year the tank was installed (ex. 1987).
<br />D, Indicate tire, tank capacity in gallons (ex. 25,000 or 1€3,000 rtc.).
<br />11. TANK C OMIE I
<br />A, 1, If MOTOR VEIf1C LE IUFI , check box i and eompletc ilems T: & C,
<br />2. If n;s= MOTOR VEIJVTIF. F €,F,l.., }.,la{.. ins appropriate box in section A and complete items I3 & D.
<br />13. Check the appropriate bor.
<br />C. Check the type of MOTOR v'F>IIICF,F; FUF=,L, (if box 1 is checked in A).
<br />T). Print the chemical same of the hazardous substance snared in The tank and the C:.A.S. . (Chemical Abstract Service
<br />number), if box L is NOTchecked in A.
<br />tl. TANK C M 3C TO - MARK. ONE TIT)s'aT C NI N IN BlyX A9 11, C.
<br />1, Check only acne item in "z"ypi, s)F Sy' f F.irl, ",F? NX Iz TY,"12IA =, i?T ]FE'RIOR LINING and CORROSION i'RC)°i"YCFION
<br />2, If 0THlyR, print in the space provided,
<br />IV. PIPING INFORMNIION
<br />, Circle A if above round`, circle Uif underground: and Circle both if applicable.
<br />2. If UNKNOWN, circle; or If OTHER, print in space provided.
<br />s. Indicate the 1..1z.AIC Ftl.i`FC`11€ 'a systems) used to comply with the monitoring requirement for the piping
<br />V. TANK LPAKDFI $ ."1`FC)
<br />1. Indicate the LFAK DEI'h.0"TION systems) used uo comply with the monitoring requirements for the tank.
<br />. INFORMSDON ONTANK PER A CEIVILY CLOSED IN PLACE
<br />L I;,5111 .A IED DAt1" HAST ST -1) - MOINTI(N1:A (January, 1,988 or 01/88).
<br />2, E,91 MA'I`Tid) QUA.YFTI Y of HAZARDOUS SUBSTANCE" remaining in the tank: (in Gallone).
<br />3. WAS "i:' NK TILLFI) WITH I'a,YERT MATFRIAL? Check or'NO',
<br />APPII( AANI' F'1" SIGN AND DAIIJ311F, T AS INTHQVIT0,
<br />I ,1;I'i2.1IC"F1ON FO "I)IE LOCAL AGEN(IRS
<br />The state underground storage tank identification number is composed of the two digit county number, the three drat jurisdiction
<br />number, the six ;islst futility number and the sax digit tank nutatber. °I'lte county and jurisdiction numbers are predetermined and
<br />can be obtained by sailing, the State ( elf, )_3a_y.;21, °Ike facility number snot be the same as shown in farm "A The
<br />tank number may be assigned by tlas trsea3 alcn y, lt�, �° ger; this number must be numerical and cannot contain art alphabet. If
<br />the local agency p,afers th. State Ia as d ioassign the tank number, please leave it blank,
<br />rFT IS tll'IFE ]III -SP N ILILOlY C)F 1°1IFa, L.x)C AL AC)11t ., `MAT INSPIX7VS 17.111 FRAC. `I' TO VERIFY11TE
<br />AOCURACY OF1111S I TORSI "I` 0M `III]* LOCAL ACs NCY IS RE-SPONSIBLE POR 111E C°OMPI Fs"TION OF 111E*LOCAL AGENCY USE ONLY' INIsORN1JV11ON BOX AND POR FORWARDING ONE. FOR *A* A 13 Aa ' )C"IA'1ED
<br />. 'Fr(s) °TO ` TIE 11311,0WING ADDRBISIS,
<br />"ATT' OFCALUtORNIA
<br />T'A"IL "SCA TM Ia U CF CC1;'`CROL BOARD
<br />CIA) L*. .EIL:1y.
<br />F')ATA PROCESSING CTN--q? C
<br />P.0 e BOX 577
<br />TA AMCCNC, CA 4`72-3
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