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INS-MUC11ONSFOR COMP1171ING,11c)I
<br />GENERAL UCIT.ONsm
<br />1. One FCIZ "13" shall be completed for each tank for all NFW PE 'N, PERMIT Cf . NGES, E OVAI n and/or any:
<br />other `I"ANK INIZORNWEION C" IANGE.
<br />2. This form should be completed by either theE 1 PLIC'.A 1° or the LOCAL AGENCY UNDERGROLTNI)TANK ,
<br />INSPE `O
<br />1 Please type or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are making 3 copies.
<br />FOP OF FORM. WARK WARONLY ONE rl
<br />1. Mark an (X) in the box next to the item that best describes tite reason the form is being completed.
<br />1 Indicate the D13A or Facility name where the tank is installed.
<br />1. TANK DESCRIPTION - C0MPIHI`E'1,)" rl"II S - IF INKNOWN - So SPECIFY
<br />A. Indicate owrriers tank ID # ® If there is a tank number that is used by the owner to identify the 'tank (ex. AIi70789).
<br />B. Indicate the name of the company that manufactured the tank (ex. AC vIE TANK 4i1 Ci.),
<br />C. indicate the year the tank was iemtallec (ex. 1987),
<br />l). Indicate the tank capacity in gallons (ex, 2.5,(.)00 or 10,000 etc.).
<br />Il. TANK C O 'H I S
<br />A. 1., If 0`rO L VEi IIIC LE FUEL, check box i and complete items F3 & C.
<br />2, If not MOTOR V13 IICLE ICU 7L, check the appropriate box in section rA and complete items B & I),
<br />E. Check the appropriate box.
<br />C. Chcck the type; of ytO"i`OR VEIIIC;I,E FUEL (if box 1 is checked in tA),
<br />T?. Print the chemical name of the hazardous substance stored in the tank and the C.A.S,#. (Chemical Abstract Service
<br />number), if box 1 is NOT checked in A.
<br />1H. TANK CC) ISFRUC:HON'- MARK ONE MW NLY IN BOX A, I3, C & I)
<br />I. Check only one item in TYPE 01. SY I`EM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTEC FION.
<br />2, 1f OTHER, print in the space provided.
<br />IV. PIPING I C)RMATI0N
<br />1, Circle A if above ground;. circle it if underground; and circle both if applicable.
<br />2, 1f UNKNOWN, circle; or if tT HE IZ, print in space provided,
<br />. Indicate the L,EAK'Diq C:1'Ii N system(s) used to comply with the monitoring requirement for the piping.
<br />V. TANKLEAK I INTIX71 € N
<br />1. Indicate the LEAK DE`17EC'HON_syste t(s) used to comply with the monitoring requirements for the tank.
<br />VI. IIN:ORMA'113N ONTANK ER NEN1'1.> CLOSED IN PIAC;1I
<br />1. 1-511MA°TED DATE I.AS'T USED "D - Si O IJYI°AFL (January, 1988 or 01/88).
<br />1 ESTIM. /V1'I I> OUAvury of HAZARDOUS SUBSTANCE remaining in the tank (in Galleins),
<br />3. ; `AS'l."ANK FILI:FD wrni INER71` M.NFERIrAI,? Check'l'es' €ar' O'.
<br />APPI,ii' , T MIJI �F SIGN AND I), °i`i?'1HF K)RM ASHNI'I II,
<br />INS1'RUC 110N FOR "111E LOCAL AG C.`I S
<br />The state underground storage tank identification number is composed of the ovo digit county number, the three digit Jurisdiction
<br />number, the six digit facility number and the six digit tank number. The county and Jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (916)739-2421, The facility number must be the same as shown in form "A". The
<br />tank number may be assigned by the local aigency, however, this number must be numerical and cannot contain an alphabet. if
<br />the local agency prefers the State Bard to assign the tank number, ,lease leave it blank.
<br />I'1" IS 111H RESPONS ISII,rFY E)It THE WCAL AGT?NC7Y 'nIKl' 1NSPLTX.`PS `11 W I?AC; I, '1"() VERIFY 'I' II!
<br />AC C: OP111E INFORMATION. '111E LOCAL AGENCY IS RESPONSI13Ix1: IN `ITIE COMPI,I4 ON WIWI
<br />R C'�rAL AGENCY .ISE ONIV INFO 'TIC)N BOX AND I R R ARDING ONE FORMW D A:1 CTfII liD
<br />SrIVI'E- OF CALIFORNIA
<br />C/o . .1r
<br />DATA PROCESSING IMS
<br />P.O. IBX SZ7 ,
<br />PARAMOUNr, CA 90723
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