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<br /> GENERAL iNS<RU r ION1,
<br /> shr . T. ' i r 30 „„a < �wr all NEW
<br /> PERMITS. PERMIT
<br /> CHANGES, REMOVALS
<br /> and/or
<br /> n}/Qr an
<br /> y
<br /> ?.
<br /> 01S l o ,i. 7houll be comply5Welthov thp PERMIT APPLICANT or ,.,he LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR,
<br /> r
<br /> 4 Use, a hard , o i Y). w4 C”r a i nsi r., ):r5' on,aS e making 3 copies.
<br /> TOP OF FORM: 'MARK ONLY ONE ITEur
<br /> I Mark an W in the :ox noxi n the item Etat best describes the reason the form is being completed,
<br /> indicate.e„ h `�7r t 1v i .", t 6 h ..
<br /> nri« �..�t,.cT t, R .. �... y r...rr=_� r�P',,r'�:; t � t.r,Fr'=k 'dS 1nStal"�i�a:
<br /> I . TANK DESCRIPTION' CAME ALL ITEMS IF UNKNOWN - SO SPECIFY
<br /> ,, owneV identify A. 1"�`r �„,. ✓� ; _ , .. if t�:' t ''; €' z•1!!r; number e1" f.lir,., is t,Sf't� t, fC;
<br /> (e
<br /> b.� the o "e' t, fy t.hca Lank
<br /> F !r0catp ' eVe mama o¢, the (::m .,r p`. tin 1 marufactu,ed ,.lib tank (ex. Ai.l`E TANK MFG) ,
<br /> u 6
<br /> o tip year -10 tank wav irsiviled (ex, 1987),
<br /> 40wate the tank capd( ity in gal7oris Tex 25.030 or 10,000 etc.)
<br /> II. TANK CONTENTS
<br /> A. 1 11 k? r1O „ kL ili, _i: FhG. C.h}l.o .)ox 1 43YTM1 complete tt4?rIS
<br /> 2. 11 not M0 `i „ d{ f! ? ' ';t.'i. t heck the r r i ipr i ate box in section A and complete items B A 0,
<br /> C. Check t1w ty1m of M01OR AHIC! f FJq L {i7box-I is checked in A).
<br /> D Print, the chrmii,cal d dnv of the hazardous subs?:ance stored in the tank and the C.A.S:O. (Chemical
<br /> Ab`. r, i.t r,R?hviCo rlerlil)i.`). 1 f h,'x 1 I`,.N0( t'rleCktrEl !C1 A.
<br /> III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN PDX A, B, C & D
<br /> „ or
<br /> iv c..i. i= ti° ITeM in Ty;4 ,.„ rr' IANK M;aT_' _AI;vTt.R;`i;r, 11NIN5 and CORROSION PROTECTION.
<br /> 2 1 f 00 2, P }nt i r the pt e pr,,Xi
<br /> IV. PIPING INFORMATION
<br /> 1 Cti- lr: A if above ground ircic if underground, and circle bath if applicable.
<br /> 2. if UNKNOWN circlei or of OTHER, prix „ in space provided
<br /> 3. indicate the EEK € - ;`.TIO systemCs) used to comply:with the monitoring requirement for the piping.
<br /> V. TANK LEAK ,DETECTION
<br /> 1 , indicate the LEAK DETECTION syst.em(s) used to comply withthemonitoring requirements for the tank.
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> ESTIMATED i„ i E LAST iI.SED MO H Yt ( a 'y, 1988 o 01/88) -
<br /> 2. E ra 05ANTITY of HAIARDOUS SUBSTANCE remaining n the Dank (in Gallons) .
<br /> 3. �
<br /> TANK .,ti._.�.[] -.Vr l 7 i 1NER!L„Y r't .,, k t,i w Check��'Y. r...„, p�
<br /> WAS ..rd, or *NO'
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCA.. AGENCIES
<br /> The state underground storage tank identification number is composed of the two digitcounty number, the three
<br /> digit jur €s ; w4 on number, the six digit facility nu"it`er and the six digit tank number:. The county and
<br /> jurisdiction numbers mber< aY e predeterminea and can be ;obtained by calling ;the State Board (916) 227-4303. The
<br /> facility number must, be the same as shownn form "A° The tank number .may be assigned by; the local agency,
<br /> however, Lhi umo must ;e numerical and .cannot, contain an alphabet. If the lggal agency refers the State
<br /> Board to a;sil'CY„ the tank ;number, please leave 101ink.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE FOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF- TILE "LOCAL AGENCY USE ONLY” INFORMATION BOX
<br /> AND FOR FORWADING ONE FORM "A' AND ASSOCIATED FORM` "B"(s) TO THE FOLLOWING ADERESS.
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