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IMp;TR C,_,TsCy`S TIOR Calla k'1Jq S1 ,1FOpM. 'tt
<br /> GENIMAL I S ' taCNO S:
<br /> 1:. One FORM B" shall he Cornpieted For each tank for alINENV PFRM N, P Ul'CHAN ES, H.MOVAI and/or any
<br /> ather'I:ANK 1NP.) t A`1`T0N CdTA GE-1
<br /> 2, 'Nits form, should be c€»;aplered by either the T'ERNUF A C'.ANI'or the LCAT,AGI; C Y UNDERGROUND 17A NIK
<br /> :3, Please tare or post z eariv a L r clucsted information.
<br /> Use abd PLI€tt- rrtra i= tr gt� ilii y�xz are nntkbna ',copiaa`.,,
<br /> 1., Mark a-,n ()j1 it, the box net o the ;(cm that best desc;rr`bcs the reason the form is€rein completed-
<br /> 1 t :tic DBA or Facility name where the tank is 'installed. '
<br /> a
<br /> . '`Al K E)E SSC RII''T IO -C0M1'1J`IV Aid,rndYIS a'1117'UNKNOWN SPECIFY
<br /> A. Indicate owners tank TI) # -If there is a tank number that is used by the owner to identify the tank(ex.AB70789),
<br /> B. indicate the name of the companythat manufactured the tank(ex,At; IC'I'ANK MFG.).
<br /> C;. Indicate the year the tank was installed (ex. 1987),
<br /> Indicate the tank capacity in gallons (ex.25,000 or-100),C)
<br /> 11. °EAI K C CTI�i t E'sS Tru
<br /> A, L I4 V),'f`0R VETI1C L 1`121-14, chc<acbox 1 aa?d coniplete items,B& C.
<br /> 2, if not 01'OR k I;iITt;C.I,i t.I I.;. check the appropriate box in section A and complete items I3 cC D,
<br /> 13, (;heck,0.x aprpatcrpriaatc box.
<br /> Check .,t;c,typsz of MUTDR R V r.,I11C LE FUL1(ii box I is checked in A).
<br /> T), print ihf,.chemical name of the,hazardous substance stared in the tank and the C°.A.S. . (Chemical Abstract Service
<br /> na nbe.),if h nx 1 is Nt,`I°chi ked in A,
<br /> TTI. `TISK(f) S-rRUC711 yiq-MARK ONE,1I'IR.fI ONLY tat B1BoX A,E3,CF&T)
<br /> 1. Check =y one i€fie,rr in'l-nPE ()F y"<' 1 ,+9,'C,,`\\IC '1;xN1 At„ P7F.RIOR LINING and CORROSION I'12C)J'FX7110N
<br /> 2, If£TI11-E ,print in, the; sp ae; prnr,r�at.d.
<br /> TV. PIPING INF()RMAITON
<br /> 1. (Circle A if ab€ve ground:,circle 1w if un0crground;and circle both if applicable.
<br /> 2. If UNKNOWN,circle;or if CYblHE I1„print inspace provided.
<br /> 3. Indican the LAK i.3UIUC ON systertt(s) used to comply with the monitoring requirement for the piping.
<br /> V. '17ANK LEAK DUUIX-TION
<br /> 1, ludic. c.the I I?` E1'11'C1.110systern(s) used to comply with the monitoring requirements for the tank,
<br /> T. I FORM- "T"IO ON°EANK III;T1 AbTU I1, C UCKSED IN PI C:°.
<br /> 1. `I'IMPI'V DNl" l TAS`R'h,SFD- x'fC1:o'1`Ff/T',A (January, 1988 or 01/88),
<br /> 2. F` I I'4I,y`IUD Ql3.y"C`i`l'f'Yof 1TA7A-?U'rtTF S SUNI'Ir'NC:1 rcrttaininp in the tank(in Chileans).
<br /> ". WAS'YANK FILLED 0"111; INER'I'MA1ERIAL? C'hoo '"fes'tar CHIC)',
<br /> AE'IsUCA 'I U,';.T SIGN A. k1A"i'Ts Pil11',FORM AS TND I("W17-I).
<br /> _INSYRUCT'HO T ) `1TE U)CAT.AGENCIES
<br /> t he state undcrground storage lana 4.,.ro6,, c 6c,,n nuniber is composed of the two digit county number,the three digit jurisdiction
<br /> ntn nbcr, the w;x digit thesix digit tank. number. 1`he county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the .;t<a,. Board (916)"739-2421, 'I`he facility number must be the same as shown in form"A". 'Ibc
<br /> tank nunibcr array fie a idncd br, the 4x,,al agcncyhowQvcr, this number must be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board tc> issi=,n the tank number,please:leave it thank.
<br /> ICT'jsnilui EtUSPO tSIBILFIN 01r"IME 110CAtT,ACIINC""'11NI'INSPI "I a'ITIE F?AC'IU1' 'M VERIFY"E`IET? '
<br /> ACF(" i C;`y'OF'I'I I ItORMtV[ION, '17IE ".AL AGENCY IS RESPONSIBLE FOI 111E?(`)MPUTI10 OF 11 I?
<br /> "LOCAA,AGENCY 3SE?ONLY'INIrCIRMWI10N W)X AND IUR 1UR AIBE)ING ONE R) 'A*AND A&'a()C,'IA 111)
<br /> O 'B'(s)' 111E IrC)T.LO IN i AE)B)IT°S&
<br /> F)V11;OF C-AIAIN)RNIA
<br /> :/ . .P I.I.S.
<br /> DATA PROCESSING 2NI`i,R
<br /> I'xe C)K S27
<br /> ICA MC)UNI-,GA
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