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<br /> Cs MUC 17ONS TUR CO PL.f 'IN "s Iq
<br /> GENERAL IN,%'RI1C PIONS;
<br /> 1. One FOII'M"I3"shall be completed for each tank for all NPW PFi ITR CIJANGY11REMOVAIS and/or any
<br /> other TANK INFORMATION(MANGE
<br /> 2. This form should be completed by c°ither the VFRMYr APDL.CI`sir the LOCAI..AGFN(.Y UNDERGROUNDTANK
<br /> INSPECT' R
<br /> 3, Please type or print,clearly all requested information,
<br /> 4. Use a hard paint writing instrument,you arc, max g.1-copies.
<br /> t. Mark an (X) its the box next to the item that best describes the reason the form is being completed.
<br /> 2. Indicate the DDA or Facility name where the tank is installed,
<br /> E. 'IANIC DSC IIL)P1- I'L'.P1 . ,rl-E s'-I r UNKNOWN-, :(
<br /> A. Indicate owners, lik E ti e;tank{ex.A1370789).
<br /> 9}.
<br /> B. Indicate the name of III,c�ampat ethat manufacturcd the tank(ex,AC;�1T?rTANK G,).
<br /> C. Indicate the year,the tank�<as;n9ta'tcd (cx 987).
<br /> I). Indicate the tank capacity in gallons,(cx.2,M)or 10, etc.),
<br /> It. TANK CCLN`I';N70,
<br /> A. 1, If MO',f0R VI IIIC LI I Ul'_I,, check box I and complete items B<& C.
<br /> 2,If rant OTOi1 y�l;1IIC, LE check the appropri ate box in section A and complete items-B & D.
<br /> B. C'hmk the appropriate box.
<br /> C. Check the type:of ISCYI'OR VPIIIC LY" FUEL(ifboxI is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S, .(Chemical Abstract Service
<br /> number),if box"I is NO17 checked in A.
<br /> III. 'EANK CON I RU('170 -MARK ONE"L"[TN ONLY IN BOX A,L3,C&II '
<br /> L Check only one ificran in"l"YPE 01'§'STE,'M,"t'A:NK MA'I`Is}ZTAL, WITIRIOR LINING and CORROSION I'Id(°)T C'I"10 .
<br /> 2. If OTHER,print in the space provided.
<br /> IV. PTMG INFOR )VIIC
<br /> L Circle A if above ground; circle Cl if underground; and circle bath if applicable.
<br /> -2. If UNKNOWN, circle;or if OTIll"I:L,print in space provided.
<br /> 3. Indicate the LEAK D I I—110N system(s)used to comply with the monitoring requirement for the piping. .
<br /> V. TANK LEAK DITIEC 111
<br /> 1. Indicate the LEAK I2ETFI C"PION system(s) used to c6lttply with the monitoring requirements for the tank.
<br /> VI.,INIX) A'nON ON TANK P R ANTINJIM CLOSED IN PLACE
<br /> 1. F-s`MATED DATF LAST I;SIrJ)-M0NT1'IJ,1YI,1'AR(.Ianuaty, 1988 cart 1/88).
<br /> 2. ES11MMATI~I)Q AN1 7I"I Y of IIA7.,%RD )t S SL BS YANCIi, remaining in the tank(in Gallons).
<br /> 3. WAS`h1 K FILLED 4"tI'II Ligl Fl I` A"1L ICIAI�?C heck'Yes'or'NO'.
<br /> APPI I , I' ,a;F SIGN AND D III'11W,FORM AS ININCNIED,
<br /> INS'MUCITON R"ITIS LOCAL AGENCII.3S
<br /> The state underground storage tank identification number is ci nnpos'ed'of the two digit county number,the three digit jurisdiction
<br /> number, the six digit facifity number and the six digit tank number, The county and jurisdiction numbers are predetermined and
<br /> can be obtained try calling the State Board (91.6)771I-2423. The facility number must be the same as shown in form"A', The
<br /> hank number may be assigned by the local agency, however, this number trust be"anumeridarand cannot contain an alphabet. I
<br /> the lira[agency prefers the;hate Board to assign the tank number,please leave it blank '
<br /> TI'IS"CIU:-R1&SP0NSIBH1I'Y OF TI 3 I X AL AGI CY'I'[IN,['INSPW71-S`IIID FA(M '110 VERIFY 11111
<br /> AC . (; OF'171E?INFORMATION. '171E I C)C' .<AGFN(Y IS RESPONSIBLE FOR11113 COMP 110N 011711II.
<br /> 'L .AGINCY USE ONLY'INFORMA17ION BOX AND IUR FORWARDING ONE 17O !A'AND XSSO(3ATED
<br /> IURMR"a "T C)`i"IE L='€11,0 ING ADDRESS.
<br /> IA'ITs OF CA11FORNIA
<br /> 3I°Am WA`IER RESOURCES CONIMOL BOARD
<br /> C/o S,W.I.K.Pel
<br /> F.O.BOX 527
<br /> PA C)UNI`,CA 90723
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