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IbT x.i' IJC'I ONS FOR CCC)MM III'ING I? -lig
<br /> 1. One F(.)RM"Ij" shall be completed for each tank for all NEW F FR o,I ERWI'C HANGED, REMOVAIS and/or any
<br /> other'T°AA INIX)RMA711ON CHANGE.
<br /> 2.: This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK
<br /> INSF"$ I R.,
<br /> 1 Please type or print clearly all requested information.
<br /> G: Use a hard point ua•iting instrument,you are making 3 copies.
<br /> -Foli 01l IN)RM:'MARK ONLY ONE FFEW
<br /> t Mark an (X) in the box next to the item that last describes the reason the form is being complete.
<br /> 2. Indicate the ILIA or Facility n<aie where the tank is installed.
<br /> I. TANK DaSCCI2 HON-r-944PI X1-1?,Au.rn -III ITNKNOWN-So SPECIFYt=
<br /> owners, that is used by the o er to identi(y j,9 ap.thnk(ex.AB7€7,99).
<br /> II. Indicate d ernad of the l,t nary that rnan facts rcd the tank (ex.ACMETANK MFG,),
<br /> C.'„ Indicate the:year the tank was iii ,all d (cx, 198f ,
<br /> I). Indicate the tank capacity in gai€sac. (ex,250000 or 10,0%,'
<br /> H. TANK CONTE 14
<br /> & 1. Tf•MC3"t OR VEHICC11"FUEL,check box 1 and complete items B&C.
<br /> 2, If not MOTOR VE11101,F I:I,,check the appropriate box in section A and complete items B& D.
<br /> I3. Check the appropriate box.
<br /> C, 'Check the type of MOTOR VFl IIC I I r FUST if box 1 is checked in A).
<br /> D. Print the chemical name of the hiz ardous substance stored in the tank and the C.A,S, .(Chemical Abstract Service
<br /> number),if box 1 is N T checked in A,
<br /> IIF. 'I'ANK CCONS'rRU C)N-WXRK ONE"I'I'T,M ONLY IN IBX A, T3,C&I
<br /> 1.. Check only one item m'I'YPT7 01'SYSTEM,`IyA iMjVI'F:1RTAI,,INTEMIC)I2 LIMN. anis CORROSION I'I OTEC 1,10 .
<br /> '2. If OTHER,,print in alae space provided.
<br /> IV. PIPING INFa'C)ICMA.31ON
<br /> 1. Circle A if above ground; circle J if underground; and circle both if applicable.
<br /> 1 If UNKNOWN,circle; or if 0'17 11fft,print in space pft,)vided.
<br /> 3. Indicate the I.LATC D I I;t:I`ON system(s)used to comply with the monitoring requirement for the Taiping,
<br /> V. TANK LEA I)FI1 TlC'F It D
<br /> L. Indicate the LFAK E 'I:C TION systernO used to cranply with the monitoring requirements for the tank.
<br /> VI. INFX) A°TI0N ON TANK PlUtMANIN11Y CLOSED D IN IIIA_'
<br /> 1. FSCIMA DATF' LAST"T SID-ivlf3:'7111IYI;AIC(January, 1995 or 01/ ).
<br /> 2. ESTIMATED C T,ANITI—of HAZARDOUS SUBS ANNE remaining in the tank"(in Gallons),
<br /> 3. WAS`['ANK FILLED AA'I'nl INIaRT iM.,\ TRIM.,? Check'Yes'or'NO',
<br /> APP110%Nr MIJ,51'SION AND I)A'I1411 ff=FORM AS )ICC F EDS
<br /> FNS U(71I0N 170111111.1 LOC".rA ,At"sENC I -a
<br /> The state underground storage tank identification number is composed of the mo digit ec unity number,the three digit jurisdiction
<br /> number, the six digit facility nur be.r and the six diab tank number. The county and,jurisdiction numbers are predetermined and
<br /> can be obtained by catling the :hate Board(916)-j39-2421, ',phe facility number must be the Santee as shown in form "A', The
<br /> tank number may assigned by the local agcncy4 however,this number must be numerical and cannot contain an alphabet, if
<br /> the [rear agency prefers the State Board to assign the tank number,please leave it blank.
<br /> rl'IS T1W.RESPONSIB1111"Y OF TIIC WCAL AGI C:°Y 11INI'INSPW JN, `I IE F ACCI '10 VERIFY'I TT?
<br /> ACCCU CTY C)F`nHi INFORMN110N. ''III'LO(W.,AGENOY IS RENPONSIBLE FOR 1I111 OMP1 -1110 OF111E
<br /> 'LO(AL AGENCY USE ONLY'Fi'dPO A'110 AND FOR IX)RWARDING ONF'I *A"AND °` a ' t)
<br /> IX) 'B'(s)TO ITIE MILOWFNG ADDRESS.
<br /> 9,rXrE WJV11,ffR REMOURCI.N COWROL BOARD
<br /> C/o S.W_I?I I'aS.
<br /> DWEA PROCESSING CENITIR
<br /> PD.BOX 527
<br /> PAF . MOU I',CA 90723
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