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<br /> Ili #' Y'jO')NlS IsOR `.OMPJJMN( 1,Y)RI 'Tt
<br /> F rac 1 C:RsA B",,Tray be, compl{.:cd for each tate for all NEW L1 " rE ,PFRm F C" 1 NGI',S, RFMO AT:S and/r)r ani
<br /> other'IANK INFORMATION MANOR
<br /> Z This forn.,should be completed bl ;:nhe� the PERMI'J'APPI.I(ANFor the LOCAL AGENCY JN £i C;ICC?UNI,)'[a "
<br /> aSPlasC'I'C1 ,;
<br /> ". 1.tss ,a.eEd pa aat <zcgan ;aastt=ate tttK you are making 3 c pies.
<br /> TOP OF Iq;3 e SVCS rte . I_,Y GIME 17FE '
<br /> 1. Mark,as, t', )in tits; box next to the item that best describes the reason the form is being-completed,
<br /> ^2, Indictatc,the DBA or Facility narsac;w cre the hank is 'installed.
<br /> . 'IANK 1111SC RI1x1`O -C"C315C1"LEM ALI,1 1 s-If?(JNKN:I -SO s a fly
<br /> A. indicate owners tank 11) # -It thereis a tank number that is used by the owner to identify tire tank (ex.AB70789).
<br /> . Indicat€a tate naniQ of ttae company that manufactured The tank(ex.11CME" SIA MFG.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> D, Indicate 'he tang capacity in gallons (ex.25,00)or 10,000 etc.).
<br /> IL TANK C>C} 'J'C NI
<br /> A, 1. If.tii:1'tS`OR VEHICLE 1 UET 9 check box 1 and complete items B& C.
<br /> 2, If not ',10TOR`hE1IIICTI,FUEL,check the appropriate box in section A and complete items Li& I3.
<br /> B, Check>i a, appropriate €ox,
<br /> C, Check ,'ae t1gv of_„,,IO`t'OIt VVI IT(I'Ll,11-11 L(if box € is checked in A).
<br /> 1), Print the chearaical sant('e car the llsizarc pus stibst<ance surreal in tate tank and the C"»A.S.�#.(Chemical Abstract Service
<br /> numbs 1, if box I is NOT ch eked inA,
<br /> 111, TANK' C'(3 I`('III -MARK CINE rn—.1 a ONLY IN BOX A,11,C4
<br /> 1. Check ck oniy one itern in"1"`PE Eft:. YSt'EM,T,-,\NK AT1,"RIAL, INTIERIOR LINING and CORROSION I'FB.i"1"I"I::CrI"IC) .
<br /> ;E, If'Jai I1IF ,print in the space provided,
<br /> IV. PIPING INMRNI/V170N
<br /> 1. Circle A if above ground; circle. U if underground; and circle both if applicable,
<br /> 2. If UNKNOWN, circle; or if print in spaces provided.
<br /> 3. Indicate the L D1 1't CEI ON systems) used to comply with the monitoring requirement for the piping.
<br /> Y. TANK HAK I?I11 f(T]ICIN
<br /> 1. Indicatc, the 1,17A 1'1'I`p("HON systent(s)used to comply with the monitoring requirements for the tank.
<br /> I. I?xTl?Cllt"a .` O ONTANK IgERIM N13NI'I,Y C.I,C`1si'?I1 IN PLACE
<br /> E
<br /> 1, }"5'1`6M 11"D DA'11,LA91'USFD-M0\71"'1IE'YLr1131 (January, I988 or Ol f88).
<br /> 2. f',S I'i;N",-�1 ED QUANTITY of I Ia _,'\R:O S SUBSTANCE"remaining in the;tank(in Gallons).
<br /> 3. WAS't'ANK FILLED W1171 INE!,RT MATl:ERIA1.9 Check.`Yes or'NO'.
<br /> PPIR '1'MUS]"'SIGN AND DIVIII11TH MRM AS IND,IC°.14°I'1ilk.
<br /> IMUMUCIION MR ME L L, Is S,
<br /> The state utsd€xrlrrreaztd stoaaEt lank .le°.ntificaticen number is composed of the two digit county number, the three digit jurisdiction
<br /> number, the six digit facilrty rcun tai r and the sax digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can.he obta i ed b,calling the 5ta„ Ba and (916)'739-242L The facility number must be the sane as shown in form 'A", The
<br /> tank nrranbe=stay be assagaed lay the 1ociO at;eny however,this number must be numerical and cannot contain an alphabet. If
<br /> the local ag ncy prefers thr: State It care' to a sign the tank number,please leave it blank.
<br /> 1''Is mu€ES €`INSIMI IT F'I I LO(INT, Cif 1 5 `111 ['ids i 'til:?F C .I`Y TO VERIFIf 11111 :
<br /> C ,'LJR (:'i°OF 17JE I ?ORM/'I:IO . ''111?LOCAL AGENCY Is CE-SPONSIBL E 1:'()12.11113 COMP11MON OF 1111:
<br /> *IOCAL M'iENCY USEONLY'INFORINNITON BOX AND MR FORWARDING ONE FO "A7 AND A&SOC. '1"1
<br /> FORM 1701.1,() INN ADDRERS.
<br /> OF CATIF01RINIA
<br /> SIAM!,SY. 'IVR RESOURCES MT's'P (1La BOARD
<br /> C; S„' .L; S'
<br /> g1.Cr��q1ECI 511
<br /> 8g
<br />
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