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IRS`I"1CIJCIFTONS 1')R COMPLIRING FORM �B-
<br />L One F,(11d 1I .shalt. tem €.. ;_ipletcd for each tatty for all NEW PIs" I"I"I, PERmn, aIANGIPS, I IEMOVA : and/or any
<br />other', INK I I1 'CORS 11ON CHANGE-
<br />2, ']'his form should be con-ip>leted by e° thcr ihr ISI,.RMfF , ,PPI.1CAN' or the LOCW, A(;F (, Y UNDERGROUND TANK
<br />INSP °"ii' C.
<br />L Pl sa is?Ir€yt� z pont e�� rf a� l r ,tz ate€E information.
<br />rmation.
<br />4, Use ah ,rd int �'✓"v�^2§Lf..,„ 3. t,.st viii„ i`t&,y y£. v aS'tEk`niak#n'.. 3 C€?pScs.
<br />TOP 01-1 IrO : 'MARK ONLY Y Cy t F I ITT'
<br />1. Markan (X) in the box next to the iteral that best describes the reason the dorm is being coinpleted.
<br />2. Indicate the DBA or Facility name here the tank is installed,
<br />I. TANK D SC;III "9"Iti: N - C:i) F1I,t?'M A11, 1`11114,13 - IFI UNKNOWN SO SPECIFY
<br />A, Indicate € owners, tank 111 # - If there is a tank munber that is used by the owner to identify tile. tank (ex, .1}3707811).
<br />B, Indicate the name of tic company that manufactured the tank (ex. MCMI? TANK MITG.).
<br />C;, Indicate the year tire tank was installed (ex. '1987),
<br />). Indicate the tank opacity in gallons (ex, 25,000 or IWO0 etc.);
<br />II. TANK C;C MII'M
<br />�y. i. If MOTOR VI-1IIf,I E I`UEL, check lacy 'I € nd complete atelias B & C,
<br />2, If not M(YI`OR VfJ1T,CL, FULL,, check tate aprrmriatc, box in section A slid complete items I3 & D.
<br />B. Check the appropriate late boo,
<br />C. Check the type of MOTOR VIH,111CLE, FUEL L (if box 'I is checked in A),
<br />D, print the chemical name of the hazardous substance stored in the tank and the C:,tk.S. . (Chemical Abstract Service
<br />number), if box 1 is NOT checked in A,
<br />11L TANK CONSTRUCTION m MARK ONE OVIN ONLY IN BOX A, R, C & D
<br />1, Check only one item in "?"` PL' C"r' S SC.�.�I. IN-IT OR I., NTNG and CORROSION €'Rfs"i`I'X 10Ni
<br />2, If OTIMA, print in the space poi led.
<br />IV. PIPING UqMRMNIION
<br />2. Circle A if above ground; circle U if underground, and circle both if applicable.
<br />2. If UNKNOWN, circle, or if 0 111"ll, print in space provided.
<br />3. Indicate. the LEAK sy-stens(s) used to comply with the monitoring requirement for the pipirt .
<br />V. TANK LEAK ISI I"IX7170N
<br />1, Indicate the 1,1-7,AK DF,TEC,I`ION &ystern(s) used to cornpily o th the monitoring requirements for the tank,
<br />"I. I FC1RMNITON ON TANS Irl°IRMANE I eY CL,C)S D IN P1ACE
<br />1, ,S"C1 T,,NTLI) > L.' i,,AST USFD - :MOINFII/'arl.%Al (January, 1958 or 01/88).
<br />2. F.'-S-17MA'I'FD QUAN TIN of HAY-M 1CI S SUBSTANC LI' remaining in the tank: (in Gallons).
<br />S. WAS °I A FILLFID WITH INTER L"v1A"I MZIAL? Check ' 'es' or 'ANO',
<br />+i4PF'I JC'. NI' T 1° SIGN AND DATE1,171F,FORM AS IC C'I'F ).
<br />INS]RUMION FORT11111 I,C)CAL AGENCYI&S
<br />The state underground storage tains, identification. number >s composed of the two digit county number, tlae three digit jurisdiction
<br />number, the six digit .achity na ber and tile six digit tank inzmben The county and jurisdiction nuanbers are prWetermined and
<br />c=an laic; obtained by califingthe. State Board (916)739-2421, '1 he facility nu nber must be the same as shown ill feat• A'. `I"he
<br />tank nartasls,cr 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 ]board ioassign tires tarn; number, please leave it btank,
<br />`1` IS °1°111' 1I IESPONS1131t,I"1 1 C' F rI HE LOCAL AG C Y '€' `I` NSPIXn °1"131^. Ir,i° ° Y 'M VERIFY 11T+
<br />(X'U C,Y C)1a `7"111? 1I [k)ICI /V]'IOF . 'ME I )C; I, AC11:M. Y IS RESPONSIBLE,, Ir£) 111E C°>i3MP111,11ON OF 111E
<br />*I,C) ' L AGRNC ` LAST:," ONLY* INIX)R I 170 IX)AND I7OR I*C3RWARDI G ONE FORM *V I AW)CINIED
<br />JO RM IBIN) TO 11M F011,C)WING ADORES&
<br />91'XI"II W/ D!,F2 ESOUI C —S C OMTR LF m
<br />DIVIA PROCESSING SING C;F : "I'I E
<br />P.O. TIOX 527
<br />PARAMOUN'll', CA WIMI
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