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INSTRUCTIONS FOR
<br /> CCNPLETING
<br /> GENERAL INS<Rw.C; ,... .3
<br /> 9 F w ed t 1, each tan r a°I NEW PERMITS. PE N
<br /> IT C A GES, REMOVALS and/or any
<br /> cWT TANK 101FORMATION CHANGE,
<br /> T f0in lorT , .u ., be cirpiptod tq o i t h r t 1w PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> Usc, a hard point w,iling insiramert, you are making 3 copies
<br /> TOP OF FORM, 'MARK ONLY ONE ITEM„
<br /> I Mark an (X) in t i=,by x next to the item that best describes the reason the form is being completed'.
<br /> r2 indi atp tMe DBA or Fa 1 fil..y r•)mo ;v`herc the "tar`rk is installed, . .
<br /> 1 . TANK DESCRIPTION' 1OMPLE.TE: ALL ITEMS - IF UNKNOWN - SO SPECIFY
<br /> A. 'ii,,vdnnaJ ... 1 if t r.oe in ,Ya 50 r .i., yr that. is used by the owner to identify the tm'nk
<br /> y c
<br /> h 'i ,
<br /> H :rdra{ . name :
<br /> f tho C: t .nr that :r , td the tank (ex. At ~F TANK
<br /> R
<br /> l.G),
<br /> C. yegr 'l' d ' ' cf r .d (VX. '' g ')
<br /> �. �� �,,�� ,' vU r � z'-_ �,.T' roar r�,.,.M,
<br /> 41 ,;
<br /> ? �,. ..x u.,.' � ,.G -....b�iliS � jr 4�.i-. �'v t nt.."� �..J,... 1..� 10,000...etc.) -
<br /> II . TANK CONTENTS
<br /> A, 1.. IF MOTOR ki_;'I CI f FUEL, v-V1.'.', k i)ox I and complete items B & C.
<br /> J 11 not M0 5R 0HICIF f% .t + rli'ck the ap r';)p 'at,e box in section A and complete items R & Cl.
<br /> C. Check iii._ p_ern of M;gfOR ZHIC[ F Ft}I I (it bqx' I is checked in A)
<br /> E Pr'-int the chc:rmi al indwe of the hazart.lr;ris suDstaricp stored in the tank and the C.A.S.#. (Chemical
<br /> Av. m::i Qrvicc " U'nu,;.= 1. 1'p Iyn ? is NO! t_Y}E:!:;Kt'i; 1P( A.
<br /> III , TANK CONSTRUCTION 4 MARK ONE ITEM ONLY IN PDX A, , C & D
<br /> 1. Check oriv orp iipT in TIPP OF SYST? 1ANK MATFRIA! , INTERIOR LINING and CORROSION PROTECTION.
<br /> IV, PIPING INFORMATION d
<br /> 1. (,1•t�c;Ie A 7t above ground circle L' if underground. anis circle both if applicable.
<br /> 2, If UNKNOWN circle: or if OTHER,,. or;r t in space prow i d(6d
<br /> 3 IndicatR the LEAK DETECTION T TON „t{'mts) , seo to Comply with the monitoring requirement for the piping,
<br /> V. TANK LE the
<br /> DETECTION
<br /> 1. indicate th,ate LEAK DETECTION system(` ) used gra comply With the monitoring requirements for the tank.
<br /> Ie INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1, ESTIMAIED DATE LAS! BED MON;IVYFAR (jarwary, 1988 or 01/88)2. r
<br /> E _ D &ANT10
<br /> of HAZARTIS 1 :iS1 remaining in the tank (l"1 Gallons) ,
<br /> 3. WAS 1ANK FILLED W1;H INERT MATERIAL? Check 'Yes' or 'NO'
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL. AGENCIES
<br /> The "` e underground storage tank enti9icat on number is composed of the two digit County number, the three
<br /> digit ,,a li ,sa t t r i on number, the s,x digit facility number and the six digit"tank number. -The County-and
<br /> jurisdiction numbers u .ers arepredetermined and ca =be obtained by calling the State Board (916) 227- 303. The
<br /> facility number mistbe he same as shown in form "A" ' This tank number may be assigned by the local agency.
<br /> however, this nu be im s't be numerical and cannot contain an al ph bet. I f. t F .l oc l agency prefers the Stag
<br /> Board to assign theja§ num1aer, please-leave it hlgk ;
<br /> IT IS ThE RESPONSIBILITY OF THS LOCAL IGENCY THAT INSPECTS THE FACILITY TO VERIFY TOE ACCURACY OF THE
<br /> INFORMATION, "TETE LOCA! AGENCY IS RESPONSI LE ,FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AAD FOR FORWARDING ONE FORM "A' AND ASSOCIATED FORM "B"(s) TO ThE FOLLOWING DRESS', "
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