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INS- U('I1ONS MR COMP1.131IN(I I It '
<br />GEmmAl., SI`RU 7OTdS
<br />1, One FOR "F3" shad be completed for each tank for all NM, PFRMn.N;PERM I, CHANGES, IR MOVAI. S and/or any
<br />otherTANK INFORMKIION CHANGE
<br />2, 'Phis form should be completed by either the PERMrr APPLICAN17 or the LOCAL A(.')ENC.,Y U E GIRO 3 TANK
<br />INSP 'OR
<br />3. Please type or print clearly all requested `information.
<br />41 Use a ,hard paint writing instrument, you are snaking 3 copies.
<br />TOP OF FORM. * I2 ONLY ON]i I'I'I?
<br />L Mark an (X) in the box next to the item *that best describes the reason the form is being completed.
<br />2. Indicate. the D13,A or Facility name where the tank is installed.
<br />. 7I°11N DE "ICII"110N - (X)MPI.IrIV ALL 171TI S - H? UNKNOWN - So SPECIFY
<br />A, Indicate cwzles •tank II`3# -;If there as a tank number that is used by the ow-ner to identify the tank (ex. tBLi70789).
<br />B. Indicate the name of the company that manufactured the tank (ex, AC;M 'TANK MFG,).
<br />C. Indicate the: year the tank was installed (ex. li;r87)7
<br />I). Indicate the tank capacity in gallons (ex. 25,000 or 10etc.),
<br />H. TANK CC) ?N'IIa
<br />A. L If MO`I'OR VEHICLE FUI?I,, check box 1 and complete items B & Cl
<br />, If not MOTOR i'I IiICLE Ft`UE,I.., check the appropriate box in section A and complete items B & D. -
<br />F3. Check the appropriate box.
<br />C. Check the type of MOTOR VEHICLE LE FUEL (if box I is checked in A).
<br />I3, Print the chemical name of the hazardous substance stared in the tank, and the C.A,S. . (Chemical Abstract Service
<br />umber), if box 1 is NO7r checked in A.
<br />III. TANK C ON91'RUC'n0N - MARK ONE rJ IM ONLY IN BOX A, Is, C, & I)
<br />1. Check only one item in TYPE (3I' SYSTEM, TANK M:1TE'RI L, INTERIOR LINING and CORROSION PR()TEC 7PIO i.
<br />1 If (TITER, print in the space provided,
<br />IV. PIFfNG INI= III l' ICIN
<br />L Circle Aif above ground; circle U if underground; and circle both if applicable.
<br />2. If UNVCNIOWN, circle, or if O(IIIER, print in space provided,
<br />3. Indicate the LL?r . D1711,"(7110. system(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LEAK DF17X,'I'ION
<br />1, Indicate the I,E AK DETECI"I£bN systems) used to comply with the monitoring requirements for the tank.
<br />VI. INFORMA.11ON ON TANK Ia`ER ' I'LY CLOSED IN PLACE
<br />1. ES"lIMA .:D D A`I'F'', I. AST USED D - M£i. . I%YEAR (January, I988 or 01/9-8).
<br />2, I"STumzx ri a) QuA rn'Y of HAZARDOUS SUBS'T'ANCE remaining in the tarok (in Gallons).
<br />3. BIAS TANK FILLED wr.l,iI INEW17 KI-ERIAL? Check 'Yes' or'NC)'.
<br />t3PPI,I ' rUST SIG :D I XMA 11F. LATCH AS I:NDIC I'EI).
<br />INSI'RU(711ON FOR `fill? LOCAL AGE C." i?
<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 nurnber The county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (916)139-2421. 'f"he facility number must be the same as shown in form 'A.". The
<br />tank number may be assigned by the local agency-, however, this number must be numerical and cannot contain, an alphabet. If
<br />the local agency prefers the State Board to assign the tank number, please lean=e it blank,
<br />I`[' IS THE IIIA§ NS I UXIY OF TII% LOCAL AGITNC`Y TIIX.p,INSI'1X71Ii '111131?.SCI[, ` ORIF THE
<br />ACCURACY C)I' TITI3 INIk)RMAIION. 111E? LOCAL AGFNC1'Y IS RENPONSIBLE MR 1III3 C OMPIHITON C)F' 1111
<br />C'. I-CiF.N USE ONLY, IPdFO 'i" ON BOX ANIS I ll I7ORW A, DING ONE FOR " 7 AND ASSOCIKIED
<br />IAC) -B-(s) 10 ' 111 RAIDWINGADDRES&
<br />POC 527
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