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<br /> CiFNU sad,I 1 fiU4:`I Ne
<br /> i. One Iat3RAI 13shall be coinple�cd For each tank for iaHI1C PERMWIN,PUR I'I'CC11A tGES, RIr, It:1 AIA and;'or anc:
<br /> othc=r TANK INI ORIVIA'I1CtI°;f'C HANGIL
<br /> 2, This form should lie ctonple end by either the PERMITA P 1'or the LOCAL AGENCY Us DIaI2C"s tOUND'I`A '
<br /> INSPEXXOR.
<br /> 3.
<br /> Please a.ypc. t s early sit c r,cslc,mfort laU n, t
<br /> 1 Use"a haA To rat wo4int rIstsurtent.yoaa are sta king,3 chpict,
<br /> 'FOP OF FORKU WARK ONLY,ONE VIEW
<br /> .. ;Quark an ','X1 in the boy next to tlac, Acct that best describes the reason the foam is being(cesmpleted.
<br /> 1 Indir t,:.he DBA or F as€lily=n anis here the tank is installed,
<br /> I, TANK DUSCRIVI"ClN-C"1MPI,EIE AU,fll: S- IF UNKNOWNSO SPECTIN
<br /> A, Indicate (ar%ner°s r=ank 11) # .m It here Is a tank number that is used by the owner to identify the tank(ex.A 70789) '
<br /> It, Indicate ;he name of the company haat manufactured the tank(ex.ACME TANK MPG.),
<br /> C� Indicatc the year the tank was installed (ex. 1987),
<br /> Indicate the flank capacity in Balkans-(ex.25,00 or:10, etc.).
<br /> IL 'I°AT CONEENUS
<br /> A. I. If%-VO O Z V IIIC,1.1;1'`C I,I.,chc,:x box 1 and complete items 13 & C:.
<br /> 2, If no, 5,10'1'0 V I;1110 1, 1`t;1;1_check the appropriate box in section A and complete€renis'B D.
<br /> I3. ("heck !,e appropriate box,
<br /> C". Check 'hc type of%401"C1L 1111 C11.t. i C l"l (H'box 1_is checked in Ash
<br /> 13, Print taw chemical nantc of thc.h,rra alogas sub.mance stored in the tank and the C.A. .4t. (Chemical Abstract Service
<br /> numb ;),if,<„ I.s NOT 1 ch a a gad in fig,
<br /> III, °PANS(CC)NsI' fta'C_11O -MARK C NU"I'I'I, ONLY IN BOX A,11,CC&I)
<br /> I. Check c fly one i1 ora in'I'z PE() SYS-1 t"NI,TANK MATE"Rlo I„ Illi ITF,RJ 7IC.LINING and CORROSION PRO'rE,(77IO
<br /> If 01"Ifl,"A' print in the epare prl)%ided
<br /> TV. IPIN(I II FORIVA11C)N
<br /> , Circle A.if above ground,circle U if underground; and circle tooth if applicable,
<br /> 1 If UNKNOWN,circle; or if OTHER,print in space prodded.
<br /> 3. Indicate the LEAK DEI X-1100 sy"Aen?(s)used to comply csdh the monitoring requirement for the piping,
<br /> V. 'IANK 11MK D f EX 1100
<br /> ;, indicate the LEAK I)s,?31€:"1`100�,Nstsrr(s) used to comply with the monitoring requirements for the tank,
<br /> Al. IN1iC1RM 111N ON'I'ANK PIiRgtA EgTI'I,'Y 0,01SI II IN PLACE
<br /> 1. I�S1T�,at'1'% A`I7,t.r"tSI`;�fSl�Il- yJ1tJ"~�g,} �I:A (Januat > 1� car(7I f8�).
<br /> F-SI MATED t„"UA"vY11Y of Il."aZAICD€UZ8;I1;E3;°;I`r1NC E remaining;in the tang:(in Gallons),
<br /> 2, 4 Al TI,\ TC FIL El) tta1111 INI,II'1's,IA` ERIAi,” C"heck`Yos'or'NO'.
<br /> APPUcA r SS I'1SIC AND DAl'WITIF PORN AS T(WI ,
<br /> 11c state underground st raa;e tank identification number is composed of the Iwo digit county number, the three digit jurisdiction
<br /> number, the six digit facitaty number a nd the spax digit tank number, -phe county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the p'tarc; Board (916)739-"2=121. The facility number must be the same as shown in fours W. The
<br /> tank number:may be assigned by the local agency; how»ver,this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefores the State Board to assign the tank number,please leave it blank.
<br /> I'I'ISI 1Ia oNsjI3nxrY OF'OTE UX Al t?A(1LY1'Y'1X)VERIPY 171E
<br /> A C(,UAC;"7 OF`lli"rC.1l°II I W,,'i'ION, '1I1(1 Ik)CAA(1I'CIdC tri .:–SII NS]I1I 1X) 'II (-'O IHI IC)N OF"fill:
<br /> "LOCAL AGENCY L=SE ONLY'INIsORMA11ON BOX AND FOR 1 DR ARDING ONE FORM W AND A',n'IC CINIE
<br /> ]U 'W(s)`lam 11II?R I,hO I G ADDRUSS,
<br /> 'MA`11?OF CAT117 RNIIA
<br /> 'A'1 1 WNIER RESOURC_S C°C)W2OL BOARD
<br /> CCjo .1 .Jp,1 P.S.
<br /> A""A PROCENSING CMN11iR
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