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INSTRUCTTONS rTn p a f N
<br /> Is: "M .,,�:
<br /> GENERAL iNSTRUCTIONS:
<br /> 1 Oqo Qm J" Qtl 1, y7n -lei : pachn for all NEW PERMITS, PERMIT CHANGES, REMOVALS acid/or any
<br /> 60T TANK iNFORMATION CiANGE
<br /> ?t, n 10 0 W -1-„ t ' harr the PERMIT APPLICANT or the LCL AGENCY UNDERGROUND TANK
<br /> INSPECTOR,
<br /> Pludso u ,
<br /> rly a'! recuested information.
<br /> 4 Usc, t1 sy sF:.?l r U'"i t r :{ inyjru7orj, yo are making ; copies,
<br /> TOP OF FORM: _'M,ARK ONLY ONE ITEM''
<br /> I Mark: can rX ' 'r the no..) next, 0 the , .,em that best describes the reason the form is being Completed.
<br /> P indicate the DBAof - ".&i..4 I yimo wherr the tank is installed ...
<br /> I . TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN SO SPECIFY
<br /> ti .t1 ! .> jwK :', if th,ylv !v a tank i b t" that z s used t tit"� � to identify he
<br /> by _ ob�ner ti fy t tank
<br /> F t.., ' r mama of t,hl.ti.)rpony that manufactcred the Lank (ex, t4\,ME TANK MCG).
<br /> C. Imo.
<br /> �: - year ri.._, .,..' : ��>,� r ' tae i.X. 198Y).
<br /> �3 ,
<br /> D. indivan the tank rap&w, ir galins Qx 25.000 or 10,000 etc.)
<br /> Ia SANK CONTENTS
<br /> A tl MOTOR 7 Eri-FLsr check box i irrt
<br /> �1 Pte st
<br /> nns CI & C.
<br /> 2, 11 r�t�at M 9R ¢. _ [0 , heck Lho ,,,T r�:ipr i at e�box in section A and complete items B'& D.
<br /> Check o
<br /> C. Check tho 1 rpQ of M`ICT VIHliaE fIRC (itboy-his checked in A),
<br /> D Print nt; the chemical t 2}mu of the hazardous Sr("i.since stored In the tank and the C.A.S.O. (Chemical
<br /> .Ab s n.L Servic r.i'li't1: r;, i k'v� i 14 '`iii( checked in A.
<br /> III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX Am B, G & D
<br /> a
<br /> Cfm orK one item i YinySTFM l P K MA f I ri, INTERIOR LINING and CORROSION ION PRO ION
<br /> _
<br /> / it
<br /> Rrrint n }Fir c{ i'e :'4d 'F
<br /> IV. PIPING INFORMATION
<br /> ..1Crr1- A if above ground circle U ifunderground. and,circle bath if _.
<br /> applicable,
<br /> 2. If (JPvKtdOWN circle: or it OTHER, print in space provide
<br /> 3. Indicate the EAK DETECTION IO icmt ) used to compiy with the monitoring requirement for the piping.
<br /> V. TAAK LEAK DETECTION
<br /> 1. indicate the LEAK DETECTION system(s) used to comply with the mo ii tori ng requirements for the tank.
<br /> Io INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. ESTIMA&D ,. LAS! USED - MOWHIYEAR (January, 3988 or 01/88)
<br /> 2. ES110TED CLANTITYf HAZARDOUS SU S °,NS ?taiY ng i the tank (in Gallons)
<br /> 3 WAS TANK FILLED 611Py`RT M1, . } .i;`1._. Check 'Yes' ori '.NO' '..
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state un s 'r ou d storage tank identification nu r"°r i s tom 1
<br /> composed>e:a �fi the t��c digit rorty number, the three
<br /> digit jurisciclion
<br /> r 1{ ber", the x, digit facility number and the six digit tank number. .The County and
<br /> jurisdiction numbers are predetermined and can be obtained by calling the State Board (916} '227-4303. The
<br /> facility number mist. be the Sate as sh wq ,rry form "A". The tank number may be assigned by the local agency,
<br /> however, this number must, he numerical and cann,:t, crnta i n an ,a Qhabet. If the 1 oc�1°agertCy, prefers the State
<br /> t
<br /> 'B7t,1r�i to ct°aa` gYX t�1e?'1FliaY�A Y�d>i.'14sp• please leave 9t bank` t
<br /> IT IS--lhE RESPONSIBILITY OF ThE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE. LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE LOCAL AGENCY USE ONLY" INFOTION BOX
<br /> All FSR FORWIDINa ONE FClRRT -A`" AND ASSOCIATED FORM 04s) TO HE,FOLLOWI G? RE S.
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