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F SI"b2IJCC11ONS IX)1I CCOMPI_S ING FOR '117 <br /> GENERAL IN 1'RUCCI 0NS. <br /> 1. One I`ORNI '13"shall be completed for each tank for all NITIVV PERM.171-S,PERMrr CIHANGES, MO A and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. 'I"his form should be completed by either the PERMrT I'1IC AN7r or the 1A)CAL AGENCYUNDERGROUND'I"ANK <br /> INSPFEfOR- <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard Print writing instrument,you are making 3 copiesa <br /> TOP OF O :'MARK ONLY ONE Tom; <br /> 1. Mark an (Y)in the box next to the item that best describes the reason the form is being completed, <br /> 2. Indicate, the 6BA or f'ac'ility name where the tank is installed. <br /> t. TANK DESCe IV1`ON-C OMP1,11111 All,I"I°:AriS-IIS"UNKNOWN-SO S1'Mi <br /> A. Indicate owners tank Il)#-If there is a tank number that is used by the owner to identify the tank(ex.AI370789). <br /> FB, Indicate the name of the company that manufactured the tank(ex.ACCIA E TAMC MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> 1). Indicate the tank capacity in gallons (ex.2-5,000 or 10,00.0 etc.). <br /> 11. TANK CONTENTS <br /> A. 1.. If MOTOR VEHICLE,FUEL,check box 1, and complete items B&C <br /> 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items TB&I). <br /> B. Check the appropriate box. <br /> CC. Check the type of MOTOR V01IChE3 FUEL.(if box 11 is checked in A). <br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> 111. TANK CONSTR 7CCI"ION-MARK ONE rl'FM ONLY IN BOX.A,,B,C&[) <br /> I, Check only one item in TYPE 017 SYSTE ,'i'Ai°K MATERIAL,INFERIOR LIKING and CORROSION PROTECTION. <br /> 2. If Ca'E'HER,print in the space provided. <br /> PIPING IWORMAIION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if C)'T"IJER,print in space provided. <br /> 3. Indicate the LE::ATC DET"E3C1 ON system(s)used to comply with the monitoring requirement for the piping;. <br /> V. TANK LEAK I3 , T.(..71IO <br /> 1, Indicate the LEAK I)E'fECTION systenr(s) used to comply with the monitoring requirements for the tank. <br /> L 7C) A`'1C)Pd ONTANK PER A E 11.°It'CIA)SED IN PLACE <br /> E <br /> 1, F-51IMA'I'T D DATE,LAST"USI°>I)-MON IIH/YF?,AR(January, 1988 or 41/88). <br /> 2. ESTIMATED QLIANY11TY of HAZARDOUS SUBSTANCE remaining in the tank(its Gallons). <br /> 3. WASTANK F'111F D W1111 INERT. `I1,,RlAL? Check 'Yes'or'NO'. <br /> APPLICANr MUSTSIGN AND 1)A,TE'1TIE FORM AS ).( I :. . <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 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)739-242'.1. The facility number must be the same as shown in form"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 /> rT'IS°1 E RESPONSIBILITY O 77111 LOCAL AGENCY T A *INS E(71,S 121E 17AC11XrY TO VERITTY 17IF <br /> ACCURACY C)I7'ITIE 117831CF A7170 . `7111 IA)C F AGENCY IS RESPONSIBLE nIE COMPI.H110N C)17 171 <br /> "LOCAL C'AL AGI NCC USE ONLY'INFORMN11ON BOX AND FOR IN)RWARDING ONE FORMA"AND AS,SC)CaI111'E D <br /> Ik3 'B'(s)TO 11JE FOLLOWING 111)DRE S, <br /> S,AT7a lYA 17IR RiTIS TUR07S,(,X) I'R.01,BOARD <br /> o <br /> P.O.BOX527 <br /> PA OU 'I',CA 90723 <br />