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IN;s:I RUC'ITC)NS FOR COMPTHIING FIO 0fr
<br />7. One IrC7R "13' shall be completed for each tans: for all NEW PNS PERmn' CHANGES, , MOVAI S anti/or any
<br />other TANK INFORMN11ON CHANGE
<br />2. This form should be completed by either the PI1. 1'I° PL.IC'ANI' or the LOCAL AGENCTY UNDERGROUNDTANK
<br />INST$ C'.POR,
<br />1 Please type or print clearly all requested information.
<br />4. Use a hard paint writing instrument, you are making 3 copies.
<br />TOP OF FORM: 'MARK ONLY ONE rIEM"
<br />L Mark an (X) in the boa next to the item that best describes the reason the form is being completed.
<br />2. Indicate the. DBA or Facility name where the tank is installed.
<br />I. TANK ISIS 'RIPFIC N - compwrfi, ALI, rrums - IF-7 UNKNOWN - SC) SPECIFYR
<br />A. Indicate o,*mn rs'tank II.) # - if there is a tank number that is used by the owner to identify.the tank (ex. AB70789).
<br />Fl. Indicate the; name of the company that manufactured the tank (ex. ACME TAN MFG).
<br />y ( 7)
<br />1). indicaste the tank capacity a galloons (x, ,tW or 10,000 etc.),
<br />H. TANK C O aN' 7,%
<br />A, 1, if
<br />f not ,rMOTOR 1.1IICL ^ FUEL, check box 1 and complete items }: & C.
<br />2. VEHICLE FUEL, check the appropriate box in section A and complete items B & D.
<br />It, Check the appropriate, box.
<br />C, Check the type of MOTOR VEHICLE Vit,, (if box I is checked in fa).
<br />I), Print the chemical nacre of the hazardous substance stored in the tank and the C,A.S.#.•-(Clienaical Abstract Service
<br />number), if box 1 is NOT checked in A.
<br />SII. TANK CON rRUC:11O -- MARK ONE r11W ONLY IN BOX A, 11, C & i
<br />1. Check only one item inTYPE C)1' SYSTI : , TANK MATERIAL, INFERIOR LINING and CORROSION PROTF,(71710N.
<br />2, If C3"I'IIER, print in the space provided.
<br />IAC. PIPING INFCiRM)VnON
<br />1, Circle A if above ground; circle U if underground; and circle both if applicable.
<br />2. If UNKNOWN, circle; or if ()Tl- ER, pant in space provided,
<br />3. Indicate. the LEAK eased to comply with the monitoring requirement for the piping.
<br />V. 'TANK LEAX DITI I1,C'F C3N
<br />1. Indicate the LEAK DEI.'EC°I'ION system(s) used to cornply with the monitoring requirements for the tank.
<br />VL INFO A: 10N ON TANK 1`1: RMANFWI1,Y C'I ,;D IN PIACE
<br />1, E-511MATED DA11 1AST USED I) - lL1ONTFII/YEAR (January, 1988 or 01/88).
<br />2. ESTIMATE,'I) QUANT11Y of ILAZARDOUS SUBSTANCE remaining in the tank (in. Gallons).
<br />3. WASTANK FILLED wrni Ii4 xr 1NFERIAL? Check 'Yes' or 'NO'.
<br />APP11CAN717 MUS7F SIGN AND DNW11111 FORM AS C, II--M.
<br />IN 1 U( 110N R)IC "[1113 LOCAL . AC3 r C"I.I-S
<br />The state underground storage tank identification number is composed of the two digit;-county number, the three digit Jurisdiction
<br />number, the six digit facility number and the six digit tank number. T'he county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (916)739-2421. "Ihe facility number must be the same as shown ire'form "A". The
<br />tank number may be assigned by the local agency, however, this number must be numerical arra cannot contain an alphabet. If
<br />the local agency prefers the State Board to assign the tank number, please leave it blank,
<br />rr 1S °Tllr,,RESPONSIB112IN OF'nIE LOCAL ACTIN( `I1 'I' INSPIT('IN, 'I'II FACII,FT " `F Cl RIF °11W
<br />ACCTJ C " C)F TIT INFORMATION. 'III [)CAI, AGEN(Y IS RESPONSIBLE MR 77111 COMP LEMON OF "['III,
<br />-LOCAL AGENCYFJST ONLY' INPI)RMAUON BOX AND F ()I2 FORWARDING ONE FORM -Aw AND ASSOaXI'ED
<br />-B-(s) -F0 -1-11E FOILOWING ADD S.
<br />rIV111 OF (YVIFORNIA
<br />DXpA PROCIESSING CEN17ER
<br />P.O. 13OX 527
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