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L One LrCi R "I3" shall be completed for each tank for all NFW IAF? ERE I' IT 7.S, RFMOVAIS and/or any
<br />Isis form should
<br />f uid lac MXI'Ih3L°a C�ITAN E,
<br />2. completed by either the PERmn, APRuCAMpor the LOCAL AGENCY UNDER(IROUND'I'ANK
<br />I1sIS1$I^ AI)IL
<br />3, Please type or print clearly all requested information.
<br />4. Use a hard Saint writing instrLment, you are making 3 copies.
<br />`11011 OF ` k)IOvb -'MARK ONLY, Ci1Fb3a, num*
<br />F." Mark an (X)'in thL ibox next to Ice itent that best describes the reason the form is being; completed,
<br />2, Indicate the DMs, or Facifrty naVue where the tank is itanailed.
<br />I. '%it�iLt,tlLiLC33 - �C�L�F;`I'Ig rrl� I'pIF - ILt IIS CT'a � SCI SIx,C'[ . ",.,
<br />A, Indicate owners tank Fit # - if there is a Iank number that is used by the ow=ner to identify `tile tank (ex. lxF370789).
<br />Ii. Indicate the name of the company that manufactur>:d the tank (ex. AC llfl'IANK MFG= ).
<br />C:, Indicate the year the card was ms l=ed (ex 11987),
<br />D. Indicate the tank capacity in gaflo,a 25, or 10,W)etc.).
<br />& I. If N CYI'OR W"ITIC1,17 F UE11, check box land complete items B & C;.
<br />, 1f not 0°a`OR VIIHIC.I I FUEL, creek the appropriate box in section A and complete item B
<br />L3, Check the. appropri at: box
<br />Print t � thh chemicaleof name t1OR VEHICLE Ft IFI, (if box 1 is checked in A).
<br />rhazardous substance stored in the tank and the C,A.S.#. (Chemical !abstract Semice
<br />number), if box 1 is "+o,r checked in A.
<br />III. 'IAN 01ak 'OF.IICI 101,1 - MANTIC ONE', r.11W ONLY IN BOX A, I3, C & I3
<br />1. Check only one bear in 'FYPE ()Ir SYSTEWIANK M.NFERIAI.,, Il~e f'I3T2IOR LINING and CORROSION PROF C'110N.
<br />2, If C3THE' h, print in the space provided,
<br />IV. 'IF]EN s II IZORM 'TICT1
<br />1. Circle ^s if above ground, circle U if underground; and circle, both if applicable,
<br />2. If UNKNOWN,circle; or of t?`I! IL"R, print in space provided,
<br />3. Indicate the LEAK srsie (s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LIWK I)IT114A71TC)N
<br />1, Indicate the LF,AK DF_°°IIi,C;`1'1ON system(s) used to comply with the monitoring requirements for the tank.
<br />" T:. Il*tFORMA"i' O N 'IANK Ili ' NEBM1`I. � L $ IN PLACE
<br />1, 7 SI'lMA TED DA11" LAsI i,sm - fJIiTT,IYEA (Jan nary, r1984 or 01/88).
<br />2. ES'I'lMWVI` 32 QUflN711-Y err' FlAZAR O s S BS'I'ANC:E rernamin in the tank (in Gallons):
<br />3, WAS "EANK PILLED '1111 INFR'I' `A'I`ERJAI,? Check "yes, €ar'NO%
<br />APPLIcAyrr F fU' S Ca 7 AND 15 4FE 11111, FORM S I I)IC I T),
<br />IIT TC'I'IO FO °ITIIT LOCAL AGENCIES
<br />`F&rc state underground storage tank identification number is composed of the two digit county number, the, three digit jurisdiction
<br />nutnbcr, the six digit facility number and the six digit tank number. ,I'lie"county and` jurisdiction numbers are predetermined and
<br />tank nurnher may b assi'Dred Fry=. the local agency, however, this nusmt ch must be: numerical and cannot contain an alphabet. can be obtainedc allfnv tar+ `Mata. Board 9ldr 739-.421. 'I'he facility number must be the same as showat in form "A ,
<br />et. if
<br />the local agency prefem the State Board to assign the tans: number, please leave it blank,
<br />FI" BUIE RUSPONSIBlIXI-Y) ' ITA LOCAL AfTIIPdC III " IIVSI"& slams "ITS? . C:1L . °I) VERIFY TIT :
<br />ACCURA('Y OF11YE INFORM I"ITO . UIE 1,()(: &L GEN( IS RESPONSIBLE MR 111E COMPIE1710N 0171111T,
<br />111T,
<br />'LOCAL AGENCY USI; ONLY' TO ND FOR FORWARDING ONE FORM Rte. 3(WW i
<br />Ia£)IC,'4 'W(a) I'Cd 'I'I II? 'IaC)LLO INN DRI,&&
<br />S I'il`1 T, OF CMIFORNIA
<br />I I°T ' i1'IE'R RE -S L7 ,°I S C.)ONTI'ROL BOARD
<br />IO &W.F1I I .S.
<br />P.OBOX 527
<br />PARAMOUNF, CA 90M
<br />1
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