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TN,1;;1'RLJ(370N,S FOR C()M1`1Z11NG TIORM "IV
<br />GENERAL IN,51RUC11ONS.-
<br />1. OneYkAM IB" shall be compicied for each tank for all NEW PER
<br />other "1"z1 INRANIN170N CHANGE
<br />2. This form should be completed by either the P1.iRMr1'AP'P1.10W1
<br />INSPFICA)R.
<br />3, Please type or print clearly all requcsted information,
<br />4. Use a hard point writinly i�nstrumcnt, you are making 3 copies,
<br />TOP OF FORM: "MARK ONLY ONE rfEM"
<br />L Mark an (X) in the box next to the item that best describes the real
<br />2, Indicate the DBA or Facility name where the tank is installed.
<br />I. TANK DKSCRIP170N - COMPLEIFF AJ,1—r11!M.,S - IF UNKNOWN - So SIT,
<br />A., Indicate (>%,item Link 11) # - tf there is a tank number that is used b
<br />B. Indicate the narne of the company that manufactured the tank (ex, A
<br />C, Indicate the year the tank was- installed (ex, 1987).
<br />D: Indicate the tank capacity in, gallons (ex. 25,0W or 10,W0 ctc).
<br />H. TANK CONI'UNIN
<br />& i, if murm V1411CLE check boxl, and compicte items B
<br />2, If not M0,TOR V1111CLE I' ),I., check the appropriate box in sa
<br />R Check the appropriate box,
<br />(I Check the type of MOTOR VE`111C.Llt, FUEL (if box I is checked it
<br />11 Print the cbernical namzof the hazaxdous substance stored in the tali
<br />numbcr), if boxy I is NOTchecked in A,
<br />111. TANK C0NyTRUC`rl0N - MARK ONE I"1 ONLY tN BOX A, It, C & u
<br />1. Check only one item in TYII[� 10F SYSJTyI,'.FANK MATERIAL, 11
<br />2, If 011TER, print in ihc space prm4ded.
<br />IV. PIPING INFORMN110N
<br />I. Circle A if above ground; circle U if underground; and circle both if
<br />2, If UNKNOWN, circle; or if 0'1111",R print in space provided,
<br />3, Indicaw the LEAK DF',T1,,C1'l0N symcm(s) used to comply with the
<br />V. TANK 11AX DFIEC31014
<br />1, Indicate the LEAK DF1a'IT"(Tl(3N systern(s) used to comply %ith tile
<br />Vt. INFORMN1,1014 ONTANK PERMANENULY (3,0SID IN PIACE
<br />1. I,;, TIM DAIT' IA,51'USED - MONr.['I(/YEAR (Jarmary,'196
<br />2, 1.:,S'I'IiMA7'11])QUANf'I'I'YoffIA7Attl)OUSSU13,S'IANCEreran
<br />3, WAS TANk FILLF"D VIT11 I INFIRI'MATE,"R[AL? Check 'Yes' or'
<br />APPlicAmr musr SIGN AND DKIE'11IR FORM AS INDI(X,11111
<br />JWWRU(n,10N FDRAME LOCAL AfHINCIRS
<br />'Fire state underground slorage tank identification number is composed of
<br />number, the six digit facility number and the six digit tank nurnber. "Cite
<br />can be obtained by calling the State Board (916)739-2421. The facility nu
<br />tank number may bcassr-ned by the local agency; however, this number r
<br />the local agency prefers the State Board to assign the tank number, please
<br />TT' S 111LE RE.KPONSIBILri-Y ovna� i.,OCAL AGENCY 371AT INS]
<br />ACC`LJRAC'Y (M? 1111, INFORMN110N. 71111 LOCAL AGIS4C'Y IS R
<br />OLOCALAGE -N(-'Y U,4ii ONLY' INFORMYPION 13k)X AND FOR 110
<br />IM 'W(s) 10 11111 RAU)WING ADDRnS&
<br />STOVFE OF (WIFORNM
<br />SIWIE VINIER RE-S()URCH—S COMIR01, BOAF
<br />cyo smnap.&
<br />DNrA PROCIISSING (IIII-A
<br />EO. BOX 577
<br />PARAMOUNr, CA 90723
<br />Pn the form is being completed.
<br />the outer to identify the tank (ex, AB7
<br />2ME—FANK MFG,),
<br />4icable.
<br />onitoring requirements for the tank,
<br />ar 01/88).
<br />g in the tank (in Gallons),
<br />
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