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GENEWAL 5=rRU . 0NS;
<br /> 1. One I'OWNI "13"shall be completed for each tank for all N13PERmri 1,PDRmyr C HANG ?,S, EMOV .T an d/or any
<br /> other'rANK 1NFORMN)I N CHAN01
<br /> 2 This fours should be completed by c:ithe r the "IIRMrr APPEICANFrar the 1.00 Al.,AGENCY UNDE G11C311ND IPA l
<br /> T SPE :I`OR.,
<br /> 3. Please type or printclearly all requested information.
<br /> 4. Use a hard point writing instrument,y€tu are Makin :3 ccmies.
<br /> TOP OF FORM:'MARK ONIM ONE rll[�M'
<br /> 1. Markan <<"', in the box next to the it s hat best describe t„,s . <..orr the form is being completed.
<br /> Indicate 0 DBA or facility name w'be._ lie tank is installec
<br /> L TANK DflSC TIP°1ION-(JC) P1JEM?A11,117113M,1, If?UNKNOWN-'..,_;f t401?C
<br /> A, Indicate e voicrs tante IT) #-If there ,>a mnk number that is ,. «.0 by the owner to identify the tank(ex.AB70789),
<br /> 13. Indic°ate t=. name of the company tham,"nufactured the tank `.,.AC'>Mla.'IAN MFG.),
<br /> C, Indicate to ` year the tank was installed !" . 1987).
<br /> I). Indicate the tank capacity in gallons'(cx ,(XX)or 10, em).
<br /> 11. TANK CONITWIS
<br /> A. I: If MOTOR VEHICI,E FI)FIT",check box'I and complete items B& C„
<br /> .'If not f,10'r70ECEIITC;I i..FU I.,check the appropriate box in section A and complete items B& TB.
<br /> B. ("beck the appropriate box.
<br /> C,. Check c the type of MOTOR VI-1110.1" F111 L,(if box I is checked in A)
<br /> D) Print the cbernic:aal name of the hazardous substance stored in the tank and the C,ASalt. (Chemical Abstract Service
<br /> saxamber),'€t box 7 is NOTchecked in A.
<br /> TIL, TANK CON'S-UIC JC111C)1 -,MARK ONE rpEM ONIaY IN BOX A,B, :&I)
<br /> 7.. Check only e�ztu itz~etr in`l 'I'f";C)kr 5�`�1"51. 1;`I":h�IC '�Ca�'1"I;IIr�T,,I;`�'I'I;T2IC)I2 t..T:�I'�Cs"tenet C;(.)1LItC15It:&4 I'ttC)'1`IsC.I Et'1°i".
<br /> 2 If 0TI II SP,Cruet in the space provielcd.
<br /> r PIPING INIU MN1 C)N
<br /> 1 �°is�lc If�bo,e Esc>tzratr <°ircre t( atadct�ro�ael, attii ez etc;Lre7th zf ali�slncahles.
<br /> 2. If UNKNOWN,N €ircic or if 01€1}" print in space providcd
<br /> 3. Indicate the 1,1 Is 133.,II_'C.'I10N system(s) used to comply with the monitoring requirement for the piping
<br /> 1. Indic a€e,he 1,EAK T3I"ITC110 N systems)used to comply with the nioni toring requirements for the trick,
<br /> 1. 11'31 ORM/t'I"T0N ON'IANK PE1OAANPWII.Y CI,0Sl,fD IN PI CII
<br /> 1. 1-1-S °IMAT D DA'T E LAST l' l 1) -iL1C NTI1tN'EA (Janus ry, 1988 or 01/88),
<br /> 2. EStlMr`t"1`I?1)Qt)ltNl°IFY of IIAZATtZ)C)US SU BS"IANC11 remaining in the tank (in Gallons),
<br /> 3. WAS TANK TaIL11 D WITII INT'11`1';+rtAII IZTAI,.>Check. 'Yes'or'NO'.
<br /> .APPI.I(: NI" 1CIS1`%ICBM AND DNIT1111E IURM AS INDIC K1'T11").
<br /> TNS 1'IC1 SCHON FOR111E 11E 1 AC)4C T,,AC i1:NC;HAS
<br /> 'Me state underl round storage tank identification number is composed of the two digit count),-number, the three digit jurisdiction
<br /> number,the six digit facility number and the six digit tank number, The county and jurisdiction nuntbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. The facility staaniber must be the same as shown in forrtt "A". The
<br /> tank number may be assigned by the local agency; however,this number must be numerical and cameos contain an alphabct. If
<br /> the local agency prefers the;State Boatel to assign the tank number,please leave it blank.
<br /> T`'1S THE' RVSP( SHIfIXI` ' OF 7 11?I,C)CAI, GII C: 'T"II 'I'II 51'I"sC1`%'1TJE 17ACTI "T' `1"C) 11" 'LITE
<br /> CMC 7. C 011171E INFORMNITON. THE ,C)(AI>AGINC Y IS RES'ONSIBImTi FOR'IHE COMP1Is t'ION OF111E
<br /> 'I,OC°. L AGEUNCY US1.°`,t) .,'Y'INMWVX.I'lON BOX AND FOR Tai)1Z T TC1)INC.3 ONE Ff)1tneE 'A'AND SSOCI "1'1;I)
<br /> FORM1 () 1 ) 1 1I F011,0WING ADDRESS.
<br /> `maxOF : TpORIA
<br /> "Al _:: a Ste$,tk „ r ?� °t )1_ e "+ .1
<br /> Al BOX 5V
<br /> PARAMOTIN17,CA rAY723
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