COMPLIANCE INFO_1986-2007 - Laserfiche WebLink

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I II T RUC'1:°IC)NS IK)IC C°C) PHTIIN(I FOR "Tl" GENERAL I2 , I" CT . C)NS® 1. One 3aO M "I3" shall be completed for each tank for all NEW PERIVIrD3, PF r -r CSI GE—Sa, REMOVA S and/or any other TARN I O 'HON CHANGE. 2, This form should be completed by either the PERMrr APPIICAm.r or the LOCAL AGENCY UNDERGROUNDTANK 1 Please type or print clearly all requested information. 4. Use a hard point writing; instrument, you are making; 3 copies. TOP OF R)RM; 'MARK ONLY ONE rru " 1, Mark ars (Y) in tine box next to the item that best describes the reason the form is being completed. 2.. Indicate the DBA or Facility name where the tank is installed. 1. TANK 5T P`170N - COMPLEIE All. IlliMS - Iii UNKNOAFN _ SO SPECIFY A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (cx, A]370789). B. Indicate the name of the company that manufactured the tank (ex. ACME TANK FG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). 11. TANK C;C)N"I I3NI S A. 1. If MOTOR V'1311IC M.' FUEL, check box 1 and complete items I.3 & C: 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete: items B. I7, I3, Check the appropriate box. C. Check the type of MCJ'IC R VEIIIICLF I°tJEL (if box 1. is checked in A). D. Print the chemical name of the: hazardous substance stored in the tank and the C:.A.S. . (Chemscal Abstract Service number), if box I is NOT checked in A. III. TANK C.`C)NS'I"RUC;110N - MARK ONE.iM ONLY IN BOX A, B, C." & I1 I. Check only one item in'].-YPE OF S"i9r13M, °I+E1NK MA'T RIAL, INTERIOR LINING and CORROSION P X1"IVC'I"I0 . 2. If 07111., Z, print in the space provided. IV. PIPING INFORMAIION 1. Circle A if above ground; circle U if underground; and circle both if applicable, 2. If UNKNOWN, circle; or if OTTIE , priest in space provided, 3. Indicate the LEAK I3I>I°EC'T"ION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK D13717,011C)N 1. Indicate the LEAK I ETI].( 1`10N system(s) used to comply with the monitoring requirements for the tank. . INIU `17ON ONTANK PlIRMANINITM CLOSED Iii PENCE E 1, I STIMA7,1 <I) DATI LAST USED - Se O I/"Yl. AIC (January, 1988 or,.01/88). 2. E-511MATED QUANITI"'Y of FIA7A)OUS SUBS"I°ANCEi remaining in the tank (in Gallons), 3. WAS TANK FILLED WITH INERT M.AI'E L? Check 'Y'es' or 'NO'. APPLICAMr MUS17 SIGN AND I A7Mz 711E, IX)RM AS IC`.KI E3. 1N,VrRUC110N IU 'I:` E LOCAL AGENCIES The state underground storagge tank identification number is composed of the two digit county number, the three digit jurisdiction number, The six digit facility number and the six digit tank number. 1'be county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 7'he facility number must be the sameas shown in form 'A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. rI' IS 7'1113 R ., PC)NSIBII rI Y" OF I1TE I L Cp C—f TT AT SPE I"S 711E FACTIX[Y'm VE IFT °I11E C,C 13 OF "11113 INIX) MI1ON. 7`1111 LOCAL AGENCY IS INSIBI,I3 FOR'11111 COMPIE110N '+�pOF I1 *LOCAL AGENCY USE ONLY` INFOR I°ION 3 FORWARDING ONE? FORM "A' AND ASSOCIATED DORM -W(s) ) °11111 F011,0WING, ADDRESS. STAII. OF C-A11FORNIA /t) & .I3 aps. DATA PROC E MING CIWIER P.O. BOX 527 PARAMOUNF, CA 90723