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1e;9f eC" 1(N, .I4a,hR CX')It,P rI'evl,(f; 1k)RM'1)'
<br /> "'n I .'' 3 Iha ine cornpicled for each lark for all NEW PE .,PE ff C;'1JANGES, REMOVAT.S and/or,my
<br /> 2, This forn",should,be contpleled by either the ERM I` PLIC NF air the LOCAL AGENCY UNDERGROUNDTANK
<br /> titfSP "IDR,
<br /> R,
<br /> 3, Please ttr"'%c, or print A,! e"N"d,inforinatkom
<br /> s, aJsc a Nad point ��<,,as¢at� S,.z $:x L:af=€..c,., E,x'w.arc }2s,k-rng 3 cc)pYf;&
<br /> 1, liars an. (X)iti the box next tai the ftern that best de.scribcs the reason the form is being icomplcrcd.
<br /> i,ts".mato the D13A or Facility name where the tank is Installed,
<br /> 1, TANK 1)I mSC'11tFOO -C OMPIIrl71a All,I TITS-Ila UNKNOWN- SC)SPECIFY
<br /> A. Indicate oxrnc n� tank.11)# - If there is a tank number that is used by the owner to identify the tank(ex,AB70789).
<br /> & Indicate the raan e of the company that manufactured the tank(ex.ACMEITANK FG.).
<br /> C, Tndicaoc, the year the tank was installed (ex. 1987).
<br /> 1y. lyda ,4� the tank,capacl.ti•in gallons(ex,25,000 or 10,M)etc.).
<br /> 11, °I`AN1) CX) )"t;fTI'I
<br /> at, ). to ,tfYsOte r„tt:+,x,E FUE-1,_,{:=ltck box t aCL1('3ing7l,$e 7=£:Sufi B& C,
<br /> I, r..t MOTORc „e 1,c.I 1 U I; , ebec_b , c, sra„>rrat�o box in section A and complete iterns 11 D.
<br /> r 1=, l �.°,ro rl.fYFOt �1.IaIC'k.E LIFT,(i h,, I is checked in A),
<br /> D ,tava the c henniral a mne of the hazardous, stabs,rtfc_ae stored in the tank and the('.A.S, . (C'hemical Abstract Service
<br /> +un,,asp ' if box I ss N()'I'chceked in.r"t..
<br /> 111.. J NK C..0 1s 41.1 1'fC) IMARK 0NF YG,,a1 ONLY Ito BOX A,1I,C: )
<br /> ', Check only one �:C rs F.a ;'YI"I OF SYS 1'Em,'I`,-eJ\K NmltfF.P.AL, Iii FRIOR LINING and C'()12ROSION i'I2t)"IF(7110N.
<br /> IV. PIPING 11NIFORNIIA'OON
<br /> `orb_ # aS�ata,, : ,c:1I t1 rr;a rFoa ad9 at�tir.uircte bath i apptical>le.
<br /> 2, 1.NX:NOIr *;cirri ;or 11`OTI Ils1, print in space provided,
<br /> Indicate-?he 'J,,,AK)_L,.Ii THO 9ys#a,nn(s)used to comply hith the monitoring requirement for the pilhng.
<br /> TANK 11V 1;11 "I:';FIO
<br /> 1_ Ind,c.,t. the LEAK DFITI"('110y, vyrtemis)used to comply Aith the monitoring requirements for the tank,
<br /> trs )xSrt ,'"t.- r�, O<.TANK)FatsS",?«3I., "f9)f f�tX»s_I2 my2 ftCfS
<br /> t c aaivt s Fit) ATE La T SED"-S1h➢N 1 j Y I:� iti(January, 1998 tsar t}�l.f SF3).
<br /> 1 ESI' I ;III)C}UA. TFY of lbZARI)Cik,'S SIMS"l"ANC'ia remaining in the tank(in Gallons),
<br /> 3, II%AS'I;NK 17tp,1, 1i) W1111 i"n1'.WF SI. 1'FIRLAL? Check ` 'es'or!NO',
<br /> PPLIC ANY U I'SIGN a 1) ' '11'1711i I IC'.a I I
<br /> INSTRU(NION FOR 111H LOCAL AGEN00i
<br /> ,_ nate undlcrgronnd stcmage tram number=s a;caniposed of the two digit county number.the three digit jurisdiction
<br /> c m o ,_r, =h r, s !',,A6€ umbra and du *a,diga cank nunal r. The county and jurisdiction numbers are predetermined and
<br /> be obtain,;l by .,, t!,, rhe State Board (916)139-2121. The facility number must tic the same as shown in form "A", 'Fhe
<br /> mn,ls cubo. c. may be .,igan,d by the a x i a ectcy, however,this number must be numerical and cannot contain an alphabet, It
<br /> cal agemy r rt f :., tfte State I ,ard to assign the tank number,please leave it blank.
<br /> I
<br /> 0'IS"ITIS P1`yf ()Ny',, llIIXT OFT1111 1,0('., I., GFN(C,1'1 1 '1`I;NSPIXTI' `I'1IE 17A(,''H YI'Y'1'C3 VERIFY 111E
<br /> r`ri"IC'II11<'S�C'"f 1:)ft'1"1"11f,1 �1'C;sllta'I`1C)rv,. "1)ICI1,C)C ,r°ICIIxC IIZ IZ1:;SpC)1sISll11,[ I ''ifF?CPwI�T,F"1'IC)I�()l�`I`f1e
<br /> )1,O(_1N1A s`aaa;)F'NC 1`' USE ONLY''1N1tr)RM,,A310 110t D FOR FORWARDING ONE FORM'A'AND AW)C:1aV17'_,I)
<br /> FORM 1 l" &"I`I) 9 t 1l i FOLLOWING rSI)t)11I NS.
<br /> "AlSTNIT'OF CALIFORNIA
<br /> )I: A'11; 1 4i;)kl .f S C'C)k) I')L BOARD
<br /> C/0 0 S' I'ft"Y's,
<br /> 1)5;1°>1 PRO4'It,SSING 1:1' I_
<br /> s "),'dzC:X ;S);
<br /> 1 ST 1A oto :ta11a, aS g ) $ Y
<br />
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