COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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C)NS MR COMPLIE"IING,I "ISI" tII 11? I..IN I-RU(1'J.ONfSn 1. One FORM"L3" shall be completed for each tank for all NFW PI's II ` F CHANCY17A .12EMOVAI and/or any otherTANK INFOA"I"ION CHANGE 2. This form should be completed by either the PF�,Rt 1'APPLFC'.A `I'or the LOCAL AGEWY UNDERGROUNT)TANK INSP 'OR 3, Please type or print clearly all requested information. 4. Use a hard point writing instrument,y0u, are making 3 ropics. 1°C61 OF IN)RM:*MARK ONLY ObI f fi'F7 * 1, Mark a (X) in the)Sox next to the item that best describes the reason the form is being completed. 2. Indicate the 13I3r`s or Facility name where the tank:is installed, I_ 'DANK ESC:R C)N-COMPLFJH,ITEMS-IF UNKNOWN- )sS`PIa,C;R'FW , A. _Indicate ow ecs-tank 113# d It Inwre is a tank number that is used by the owner to identgf�1k tank(cx.A1370789), €3. Indicate;the name of the company that manufactured the tank (ex.ACMIETANK tvIF6,). C. Indicate the year the tank was ir�tallcd (ey. 1987), I). Indicate the tank capacity in galk)ns(sex, 25,Ofs)or 10,M)ctc.). H. ''TAMC CON' "F N`[ > A. 1. If MO'.I'(.)R VE111CLF FUEL,check box 1 and complete items I3& C;. 2.If not MOTOR VEHICLE)°`t.L'L,check the appropriate box in section,A and compete items 13& D. B. Check the appropriate box. C. Check the type of MOTOR VIIHIC l I.FUEL L(if box I is checked in A). I). Print the chemical name of the harardoes substance stored in the tank and the C.A.S, .(Chemical Abstract SerVice number),if box 1 is Nar checked in A. III. TANK(CIN I RUC'J1O d-MARK ONE rIEJN ONLY 114 BOX A,I37 C&D 1. Check only one item m 1-YPE OF Sk'STF.M,` ANK ivjVI'ERTAT.,, INTERIOR LINING and CORROSION I'fIC)`I`EC"I10 . 1 if C THEI6r,pint is the space provided, IV. PFPINCI INFORMA110N 1. Circle A if above ground; circle U if underground and circle both if applicable. 2. If UNKNOWN, circle: or if O'14III,R,print in space provided, 3. Indicate the LEAK I7T"I' C`110N sy:stcm(s) used to comply with the monitoring requirement for the piping: V. 'F"ANK LEAK I).y:IR71`F(3t L Indicate the LEAK D I F CI'l kN s siem(s1 used to comply with the monilorma requirements for the tank. INFORMA7110N ONTANK PER ANEN11, `C'I.( SF I)IN PJLACIi 1.; ES11MAT D DiV.1`I;LAST UY Iil)- 41ONFI'll/YF-,\i~e (January, 1988 or 0tj88). 2. ESI-IMAXEU C)L AINI`FI-Y of IIAZARI)OUS SUBSTANCE remaining in the gall (in Gallons), 3. WAS'I'A eK TILLEI;) WITH IN RT?xATERTAL?Check'Y s'or'NC)`. APPLY(° 'I'SIGN AND 1)A°ISI°I IF?IX)RM AS )IC,AI i3. INSTMUG1710N FOR 11111 LOCAL AGENC IE—S "Elie state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number,the six digit facility member and the sax digit tank number, The county and jurisdiction numbers are predetermined and can be obtained by calling the State board(916)739-2421. The facility number must be the same as shown in form"A'. The s tank number may be assigned by the local agency;however,this number must be numerical and cannot contain an alphabet. if the locahagency`prefers the State Board to assign the tank number,please leave it blank. ri'IS IWI RE.SPC))NSIBUXI Y 01"IFl?I O ALACHIPI ;°f°ITFA'F'INSPFA"N 171E FAO[ "IT)iI RIFY 71 11? ACCURA(TY OF ETIFA 3NIaO A`I'C)N. `111If LOCAI,AGENCY IS RESPONSIBIJ3 FOR"PTCI.CC) PIXITO OF I11IE 'LOCAL AL AGE USE ONLY*INI )IC 1`I-IO ALS() [DR FORWARDING3 ONE 7A*AND A1,&".CIKFED X) *Iii(s)TO'ITIII I't)ILO INN AI)DRE S. SENILE,OF(YUJIURNIA grA' > iVIVIR RESOURCES CON1701,BOARI) C/o S. . RP Sm ])KI'A PROCESSING MN'IE R PD.BOX 527 PAF :ri1OUNF,CA 90723