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<br /> IMS17RUCTITONS MR COMPUT NG FORM"I1"
<br /> I, One FORM, "B"shall be completed for each tank for allNEW E .,PERMn.'01ANCYPS, REMOVA1.13 and/or any
<br /> other TANK O )VITT C IIA GF_
<br /> • 2. This form should be completed by either the PERM.TI'APPUCANFor the LOCAL AG Cs"Y IITgF31?TtCB12OUND'A"Ahl
<br /> INSP a,C,"T)R_
<br /> . Please type or print clearly all requested information.
<br /> 4, Use a had point writing instrument,you arc:making 3 copies.
<br /> 1 P OF Ik) .'MARK ONLY ONE M?M'
<br /> 1. Mark an (X)in the;box next to the item that best describe%the reason the form is being completed.
<br /> 2. Indicate the DBA or Facility name where the: tank is installed.
<br /> 1. TANK TC I)1- . TTO -C"OMPI,1 fE ALL TIMMS-1Tr UNKNOWN«SO SP.a FtY
<br /> A. indicate owners tank TO #-If there is a tank number that is used by the owner to identify the tank(ex.AB70789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.).
<br /> C. Indicate the year the tank was installed(ex. 1987),
<br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.).
<br /> H. TA ;,C) .
<br /> A. L If MOTOR VEHICLE 1°'(JEL,check box 1 and complete items B& C.
<br /> 2.if not MOTOR VEHICLE,FUEL,check the appropriate box its section.A and complete items B a&I:).
<br /> B. Check the appiopriate box.
<br /> C. Check the type;of MOTOR VEHICLE FUEL(if box 1. is checked in A),
<br /> 11 Paint the,ehernical name of the haraa•dous substance stored in the tank and the C.A..S. .(Chemical Abstract Service
<br /> number),if box 1 is TvOT checked in A.
<br /> L TANKON,'T" IJCo17ON-MARK ONE rpFM ONLY 1 .A,1i,C.&1)
<br /> I, Check only one item in'IYT'E 017 S`5 slT.M,TAN MNI`EiRIAL,INFERIOR LINING and CORROSION i'ICC)"1TEC'nON,
<br /> 1 If C)TI-TER,print in the:stance provided.
<br /> . PWING WORMN11ON
<br /> 1. Circle A if above ground;circle U if underground', and circle bath if applicable.
<br /> 2. If UNKNOWN,circle;or if C)"I'HER,print in space provided.
<br /> 3, indicate the LEAK T)EiECTION system(s) used to comply with the monitoring,requirement for the piping.
<br /> V. TANK LEAK 1)1?I FX,'ITC)l
<br /> L Indicate the LEAK DE",I'ECrION system(s) used to comply with the monitoring requirements for the tank.
<br /> VIL I Ik) 7,1O ONTANK PERMANEN11M CIMED IN P . C1I:g
<br /> 1. ESTIMA110 DN ^.[,A,51'" USED-MON]I /Y , 12 (January,1988 or 01/EI8).
<br /> 2. ESTIMATED"J ED QUANrrj'i'Y of ITAT,A'RDOUS SUBSI'ANCE remaining in the tank(in Gallons). ,
<br /> 3. WAS TANK F^Ti.,i,ED W1111 INE j r mA`FFRIAL? Check''Yes'or'NO',
<br /> APP F'SKIN T)T)AT11`I11E FORM AS INDICAIM
<br /> TNS'.pRUC17ON FOR 7711i LOCAL AGRNCWS
<br /> The state underground stowage 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 (916)739-2421. The facility number trust be the same as shown in forth "A". The
<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 Board to assign the tank number,please leave it blank.
<br /> rr IS 17-IB RESTONS1131111T C)F7"TTI?IDCAL AGINCY 11IK1'INSPECINVIME FACILM 1°C)"1/1 'ITIS
<br /> ACCURACY 01T71113 X)RMNI1C) . 7TIE LOCAL AC`sENC Y IS RILSPONSIBIE 1<°C) 'T'11E COMPUNION OF`IIE
<br /> *LOCAL AGE NCC`Y USE ONLY' RMXIION BOX AND 17O IN) DING ONEFO 'A'AND ASSOCaIN173T3
<br /> ItORM'B'(s)TO-11117 FC)I WWING AI)1) £$SS.
<br /> STAI'E OF CAMFORNIA
<br /> P.O.BOX 527
<br /> PARAMOUNP,CA
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