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INSTRUICTIONS FOR COMPL � I; ° �„
<br /> GEENE, ,AI SIS �'"�1
<br /> t�, E a�.a��,;
<br /> all NEW PERMITS, PERMIT CHANCES, REMOVALS and/or any
<br /> "Atid i. f.lti4r,4 ' .i § .
<br /> PERMIT APPLICANT or the e LOCAL AGENCY UNDERGROUND TANK
<br /> 3 ,i i .,i". ;v , r"", q xt ,u t i;,,
<br /> US, ard .,,r,rl{ it+'" `'+ nrl I III S it .`re" V_i,i ?re til'tino 3 copies,
<br /> TOP OF FORM. 'MARK ONLY ONE ITEM,
<br /> 1 Murk, ar {X,• in, th, ,box rwx' . !n fl- +t,c!m i riot bf st doom"' bp) the reason the form l5 being completed,
<br /> o j idit ,a!_ tn,a .13 (,W ra i !`iv n!p, wher(, t tark is instal led,
<br /> 1 . TANK DESCRS'r 'I'ION COMPI_F€E ALL ITEMS _ IF UNKNOWN SO SPECIFY
<br /> }>: - 3!. :.,1..':' �, °,i, ', '. z+. .. i i`'. `i`' r, ": ,•.`.fx+4 '.r.I' ,.i: !" t.11+;°.
<br /> is u,se t by the ie owr'ier t. -identify the tt�:r�Ek
<br /> ai
<br /> a
<br /> 1z d c, t d._ t 41iT rr> a, nt r 4
<br /> t.ti t:7 tar" (ex. At.Ml� TANKhrF�G)
<br /> W _
<br /> i
<br /> tCi Ir•. �- .eie E....
<br /> II . TANK CONTENTS
<br /> A. 1. 'Ii M F : "Ihl; 1
<br /> 1, !ir, ��� tiCx l ar a a,�. '{.7}e e items B � L.
<br /> M: `., F. `?t ( (,,i i heci, ! d,;l "';i(:3T''r,�-(' b(1-ii in section A and complete items B & D.
<br /> B 1.,hit k C'4.i.4
<br /> C, (°hi!, -k ,l t t r+;r, o M'}ils{ 1:Hii;l l 11'i l (?f t,;x l•.. is
<br /> :.f-ricked in A)
<br /> G Prriit t.ho cheiin ail ru:,ltu of Lhe harard(,,t s stored in the, tank and the C,A,S,#. (Ch�micat
<br /> b s r 1-1- i. .r i i'_ R 1 i`, N01 r.h EEck'od in A.
<br /> III . TANK CONSTRUCTION MARK ONE: ITEM ONLY IN BOX A, B, C & D
<br /> ,_a. n y
<br /> 1 l.f iE .K err :7':' # .., y t t f '.- 7 ° + f`� !ANK VA 1 ,.pt, I N'TC-tt: s i.1 14I hG) and CORROSION PROlECT`IO
<br /> N,
<br /> '% r (bit
<br /> IV, PIPING INFORMATION
<br /> 1 Cl r°c;.'1 E A if' arc: ur;. ;r c-1 e ,_ ,` ,arr; rf,rtrrd. and cl rc<"is bath f apl i cab i e.
<br /> 2. lf''TJNKNOWN circle: or 1` `Hi:co,,. -print n'S;.ace :Tarovrd tf
<br /> Ind i..,,i,;' tris :. :-fK 1H _ �N `.y.,4em's; used ,,o c°rm,ily with the monitoring requirement for the piping,
<br /> VA TANK LEAK. DETECTION'
<br /> 1, Ind f c ate t1h Li:AK DE i EC410N sys teit>? used to comply with the mon1 tor�i ng requirements for the tank,
<br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE pp�}}
<br /> ,.
<br /> E � :+ C +If� �L. 1 i{�, ".iia ,. 1`( 1 f.,t :.'7 y`rr. lti C`(; 01/88)1. ^r E w.E <LJ + JUL, � i.i: Tainiiit � �r�i' tiYih (in idi1 715).
<br /> A,
<br /> at 14t�`; v'iV, �_._�+t ISI a L&v��. � i.?,iP�z-, �,=i:C'K Y�S Jr` �fQ
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL., AGE CIE
<br /> Tris', stat e t,3 c �i. 'L aydr ,u-, iii , f t;,c.+. on ntim.,z'r"' 1 S Cv"!1T)o,P,.a of the two d;g i t County number, the thrE'e
<br /> d 'L-ur ,st;-+c ,r i ...r;.-r per, the, `�,x d o,t fac !' i t;v number, uric: the Six digit tank number. The county and
<br /> Til'.sdict."M r.a30ers .Ee e.tte i nen rxw1'.:ar be iobt,a,ned by calling the State Board (916) 227-4303. The
<br /> 1c,cill,,.y nu"?1 I":> , e t"? safre as .shown it. f.r, "f'�", Tali tan ntambeP' .iPay-�3e ,assigned'by the local agency,
<br /> however, this numfbe mai=s be numprir,al he and.cannot .cont. ;n an- alphabet. ` if tyre local agency prefers the State
<br /> Eos d to assign tt,iiik, nail p + :.e� is ve It blank.' c
<br /> the 'ori .
<br /> a t
<br /> IT IS-TI-lE RESPONSIBILITY OF THE LOCAL. AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE LOCA! AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FOR14ARDING'ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ESS.
<br />
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