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MMUC71'I NS FOR £°OMPT14MN l IAC)
<br />GENERAL SL' C J "IC3 Sy
<br />One I'C)FI F113" shall be completed for each tank for all NEW PERM.nS, I ERMr , CIJANGE, tEMOV I and/or any
<br />`1Ot�
<br />1 This form should b
<br />other' A IIC I t C
<br />completed by cit ,., . e niRmn L,C'N'T or the L.£L.Aa: ., RCI01,T
<br />3 Sl'e pe or print clearly all requested information. x
<br />A. Use ai hard point writing instrument, you are making 3 copies.
<br />'1011 OF FORM, 'MARK ONLY ONE rrum,
<br />L Mark an (X) in Elie box next to'tbe item that best describes the reason tine: form is being completed. '
<br />2. Indicate the DBA or Fachity name where the tank is installed.
<br />I. `l: t a I 1 IC7 CI 111 1II pl Ii -
<br />IF UNKNOWN
<br />SCl S1'I: C Iii
<br />A. fraciicdlc owners
<br />Indicate the name of the company that manufactured the tank (ex. C.:Nli:? TANK �llentify the tank (ex. AI3"iY7g4>).owners tank III - If there is a tank number that is used umi? the owner to aci
<br />C. Indicate the year the tank was installed (cx. 1987),
<br />D3 Indicate the tank capacity in gallons (ex. 25,000 or_10,00tt etc.).
<br />A. 1_ if Mfyj}R V IIIC:I,F F rF L, check box 1 and complete items II c& C.
<br />2, If not MOTOR V]dIICLE F UI:L, check the appropriate box in section A and complete items B <& D.
<br />B. Check theappropriate box.
<br />. Check the type of ?vI(l'FOR VEIJ C i I , FUEL (if box 1 is checked in A).
<br />D. Print the chemical name of the hazardous substance stored in the tank :and the ( ,A,S. . (Chemical abstract Service
<br />number), if box l is '.4(;)`1' checked in A.
<br />III., TANK C ON ° 2.t 9CI O - MARK ONE E1124 ` INTLY IN BOXA, 13, C & D
<br />3.` Check only one bern inTYPE € l` SFM_Y T"1'A1NK MATERIAL, I?"i'i I ]OR LIMING and CORROSION I PRO-I'EC TI(. N.
<br />If OTITER, print in the space provided.
<br />L Circle if above around; circle U if underground; and circle both if applicable.
<br />2. , t .t I- yOWN, circle, lir of (3'FHEIRp p rant in provided,
<br />'
<br />s, Indicate the LEAK DE'l ,"C'I'lO system(s) used to comply with the monitoring requirement for the piping.
<br />f
<br />V. 77AN ,T IC I3M I? 'I:1C
<br />I, Indicate the L,F.A tt TFC tltl syste (s) used to corn ply whit the monitoring requirements for the tank., �
<br />VI. INIORMA11ON ONTANK PERMANEMILY CLOSED N PLACE
<br />E
<br />I. ESpIMA'IED l>V1'E 1AST USED - iLtf3N''I1I%Y€ AR (January, 1988 or 01/88).
<br />2. FSTIM A'I-P fFLA T "I of HAZARDOUS SUBSTANCE remaining it the tank (in Gallons):'
<br />3. WASTANK FILLED `ITHN'Ei I' MATERIA ,:r C heck > fes' or �NO%
<br />AP I.IC 1' ,�al' S G AND I)XI I'11M MRM AS MICN1111),
<br />1N,1; LTC 1l0N FO '1118 WCAL GE C'I ? a
<br />'Che slate underground storage tank identification number is composed of the M=o 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 Ikaard (916)739_2421. ' '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 leave it blank,
<br />f ., 1 II? RESPONSVINIXIT L)F MIE O(LAL A Tf( if TIlNl' I SPIRTIN 111H PA(,'ILny iu VE I Y ' M
<br />C ill t C)la IIC 1PIi 1 I . TIM, ) " AGENt ' IS SPO SIBL C "11 11 CO l i?li€!Iv( Op'II E;
<br />'LOCAL AGENCY 141 ONLY' 1NFX)RMNI1i0N BOX AND I?Ci1C FORWARDING CINE FORM i -x A ° I' D
<br />MRM 'Tr(s)TO THE MILOWING ADDRESS.
<br />SI rl' OF C', 1sIM
<br />Iii' I"I°:1 " 'pER R13—SOURCIN COMPROL BOARD
<br />c/o, S.W.1-m,
<br />Ii i P1OOESSING CEMER
<br />P.O. BOX 527
<br />ISA OUNI', C'
<br />
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