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§ 0 `-
<br /> fro,R,C"Crraall'"I.I I11N(a( r=lRN 'B
<br /> C rrICIIIkAI I�;vI°��.�.I� b:.I ?
<br /> i. >at., ?(tl ? 1, >iaa.( be zon k"t o ."o each fank for all L. ICER I"V3,I ERMIT C;I APdCaFS, ILIa.I�RC:)�AI�an ttrga.<a y
<br /> other TANK I FIOR LA'I"ICIN C'IIALaGEL
<br /> 1 '11 fo ri"n,.,should lac „on,picied by either the I"F; F A lJC'.A ' 'or the LOCAL AC;)TfhSCY UNDERGROUND TANK
<br /> INSPECYOR.
<br /> 3. Please irpc or f,-int.clearly rcol a< t?d infor`taaation,
<br /> c €.-sem a l, _ane ,,,aa are making,€nI,3 ctsfra^s,
<br /> 'IOP 4.,$I1 trt.11LNl`-'alt,,`,Talc Oblix isf4u,rn,.,mir
<br /> 3 s-lark .: t?'y,in thc box next io the item that best d :-,.ritx,,s the reason the form is being'cor pitted.
<br /> L, dal a;, the-I)BA,o, Facility nano,where the tank is instaailed,
<br /> L 1ANK I)lx IC)N-COMPIlnLl All,LI S-' 'UNKNO 'N-SO SPIXIFY
<br /> A. Indicate owners tank 11) #-If there is a tank numbt:r that is used by the owner to identify the tank (ex.AIi70789),
<br /> 14, Indicat, tnc nanac of the comp auy that manufactured the rank(ex,ACME"I°t1.N149IaCi,).
<br /> C, Indicate the year the tank was installed (ex, 1987)
<br /> D. Indicate the tank c;aapacily in palions(ex.25,0w or 10,000, etc.).
<br /> IL TAMC C ONO I`N'
<br /> A, 1. If.*vaO'LC)i°( Vi Ii1K,l E FUl,C.,, check box 1 and complete items 13 & C°
<br /> 2, If not MOTOR'S'Ctuwf,I 11,1,1, cbeck the appropriate box in section A and complete items 'B & D.
<br /> B, Cbec€ ,ac:apprt:tpriaat€a box.
<br /> C, Check, 6;„ typaa of M t"I 01Z 1 a°I11C L,I I UI'I,(€f box 1 is checked in A).
<br /> 1?, Print thcchemical naarne of the hazardous substance,Mored in the tank and the C:.A.S .(Chemical Abstract Service
<br /> naaarabc a), if box 1 is NOT checked in A,
<br /> III, TANK CrC)NS I I I311'((AION-MARK CTI?rrum ONLY IN BOX A,13,Ca&I)
<br /> I. Check k 5"dy one iteaa.€n'I`PE CTIa'_S I'Si`1TM,ICAN C MA"IT:ILIAI.,, IN-I' I=aIOR LINING and CORROSION PROTECTION.
<br /> 2. If CIIH IC,print in the space a .wet€d,
<br /> IV. PIPING INFORMIA17ON
<br /> 1. Circle A if above ground:cir Se U if a nderl rounds and circle both if applicable,
<br /> 1 If UNKNOWN,circle;' or if OT1113R, print Ora space prodded,
<br /> I. hidixaa" `lac:LEAK )L.T:I:C"[z x°,st. a,{.) used €ca con,fsly with the monitoring requirement for the piping.
<br /> V, TANK HiAK DI"I'EX-1-TON
<br /> 1, Indicate,Die LEAK UE"Yia.Cel Its*i system(s)used to comply with the monitoring requirements for the tank,
<br /> I. INFORINNFION „ l`A I, PERI-ANSN]IN CLOSED IN PLAC l
<br /> L FSFlM/V'I1q) DATE 1.Abl'USF.1)- ON Ill'N °<AR(3anuaa;ry, 1988 or 01/88).
<br /> ` ESTINI:s'E'D(IC.)A�;'1`l'Y of i1ft�AFlt {3$ S`Lf 3S"I"A�t:3:i remainin,-1 in the.tank(in Gallons).
<br /> 3. abASTANK FILLF:L) Wl'I`ll INF "T MA IAL? Check'Yes'or"t O
<br /> APPLCAMI`MUSI Siii,'iN AND DNITz" Ill FORM, AS INIC 17,11
<br /> UC 'ION 1X)R'Ji1IE I,OC AL AGENCIES
<br /> The state a nd-ergrorind tragi link itIc.ratlf,cati n raun er is composed of the two digit county number, the three di-it jurisdiction
<br /> rat>a" bcr the „x digit facility number and the six digit lark. number. The county and jurisdiction numbers are predetermined and
<br /> can be obtaintel by calling the State B>o<rrd (91617139-242L The facility number rarest be the same as shown in form "A". The
<br /> trunk number maay be woimwd lay the Toot? rI> r=y; 'however, thiss number must be numerical and cannot contain an alphabet, If
<br /> the local agericy prefers the State Board to ass.ya thettaarnumber,please leave
<br /> leaseleave itblank
<br /> tI is it TR3SPONSIBaLIT'Y 3y11 1,,O('-AT, I',Np, Alt9l'[NS : 'I+,S, $IE p6gk ,.. p Yg l-ly 171E,
<br /> ACC RAC.'"Y OF IIIE IIdSIt'C:III I!ya"I ON, 111E .IC"AI<AGENCY IS RE-SPO 5111111 i`O2`11E COMP:INTO OF 17 IA
<br /> 'I CAI"AGENCY USE ONLY'IIII'IILLNIda`UO )A)X AND IT)R ItC R ARDING ONE M .A7 AND AAs°Ki"$)C: 114'�
<br /> Is() 'I3(s)TO 1111'FOLLOWING AI)9,RH,!Ill,
<br /> I"A'I'f OF CA11FC)I NIA
<br /> S W1bl'UR RlbS,)URCIf�C;C")II'II.€)Is BOARD
<br /> OXEN PROCESSING C I{,NI'I,IL.
<br /> P,o ) 5 , .
<br /> AILACt NF`CSA 901
<br /> 'ti ,
<br />
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