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<br /> GENERAL 1NSI*1 i1C" ONSn
<br /> 1, One FOR „13" shall be completed for each tank for all N1= E?RMr ,F'ERMrF MA�NGEN, REMOVALS and/or any
<br /> other'I'ANICINIX)R ]IC)NCHANG
<br /> 2. This friar should be cornplc ed by either the PERMyr AP I1CA I'lar the LOCAL ACLI NCS' 1dDERG C)C1ND`YANK_
<br /> INti1'WPOR..
<br /> 2. Please type or print cleanly all requcsted information.
<br /> 4, Use a hard point writing instrument.you.are making 3 copies.
<br /> 1.. Nl Yrs.an�. 3 in the box, next to iFte il,"n zUa t€bc-t de:cK.t.bc ,�;w .e.�FSCAffl the form is beim'cilmplctcd,
<br /> 1 indicate 011c DBA or Iz°<acilitn nmncr an, flic, i ank is a,terda(1..
<br /> 1. TANK I)luS('RIIyl I0N- I"I TIMI ALL II"L;f L IF€ N " O N �aTI:GI
<br /> A. Indicate cv,,,ners tank II)#- If there .>,- €ank number that iu .�a lhy the owner to identify the tank(ex.A1370789).
<br /> 13, Indicate 11;v .rime of the eonlpany thea sy.mufactcrcd that tank .a.ACM ,TANK FG).
<br /> C;. Indicate 01.3° year the hank was installed u. 1987).
<br /> t). Indicate tzN,. tank capacity in gallons(cy -,M)or 10,M)etc.).
<br /> 11. TANK C ON"7"1MS
<br /> A. L If MOTOR VEHICLE,FUEL,caheck.b6x'1 and complete items I3 & C,
<br /> 2. If not IMOI(:)'1C FU11,, check the:appropriate box in section A and complete items 11 &D,
<br /> 13. Check the appropriate box.
<br /> C. Check the type c)f NICa"1'd:)17 MUCLE 1 UE (if box 1 is checked in A).
<br /> 1), taint the chemical name of the.hazardous Substance stored in the; tank and the (,.A.S.#. (Chemical Abstract Service
<br /> number), if box 1. is NC:I'I`checkcd in A.
<br /> III. 'IANIC C.OM 1"7UR 110N w MARK ONE TIUM ONLY IN IM A, 13,C&1)
<br /> 1. Check only one item in"I"YPE C)f'S"YSIT'II1,TANK MA"11',,R)AL,lN'ITRIOR LINING and C;CTRROSION PR Ta'I..C,"ITC)N,
<br /> 2. If f)"I"I.1ER, print in the space provided.
<br /> IV. PIPING INFORMMION
<br /> 1. Circle A if above ground;circle II it underground', and circle both if applicable.
<br /> 2. If!.,`cNK?4C7WN, circle; or if OTHER,print in space provided.
<br /> 3, Indicate the LEAK 33F>` EC'11ON system(s) used to comply with the monitoring requirement for the piping
<br /> V. TANK LUAK I)f.1'I .710N
<br /> Indicate the LEAK Df,, EC.`J10N system(s) ut cd to comply vith the,monitoring requirements for the tank.
<br /> V1. IIs1R)RMA[ION ON TANK PER ANItNI Y 0,0SED IN PLACE
<br /> 1. ESTIMATED DA1`1 F A5I i„4F:TS-:r ON'ril/ 'FAR(January, 1988, or 01/88).
<br /> 2. F..S1”MA` 1.1) QUAi 1'lTY of HAL-M.)OUS SUBSTANCE' remaining in the tank(in Gallons).
<br /> 3, WAS TANK FILLED WIT If IN I r MA`I'I''si7IA.L? Check"Yes'or'NO'.
<br /> AP111.IC ANT C7 'SKIN AND])A"E°1"111.R)RM AS INI3IC.A`I193,
<br /> fN';TFRt7C7I10N FO °1`I1E LOCAL AC ENCIf S
<br /> 'Me state underground storage lank identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number, the six digit facility number and the s'sx digit tank number. The county I and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board.(916)7313-2.421. The 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 /> rr IS 1111,1'FII:'wS C)NS113111I`' OF 1711-1 LOC NL AGENCY 11LIk '1NSPEC"I 1I1?FrAC1IsFY'lD VERIft THE
<br /> ACCURACY 01711 INFORA1A'I'ON. °7`118 ID AL A INC ISRESPONSIBLEFa it �1,111E:f7OM �"IO 017°1'111;
<br /> 'LOCAL AG N(Y US,
<br /> F ONLY'INIT)IC IA°I°1()N 1X)X AND IN)IC 'C) AI21)Ii?i 3,ON1 FOR °.A"AND AS.f>()CIA'I't'.)
<br /> FORM-Ir(s)-ID'111EFOLLOWING,AJ-M)Rli%
<br /> .1A71€17 CALId:'C)pNIA
<br /> M1`,A"I'F WA77FTY, 71"2,z°0 r RC1. R`. r i t ll.,BOARD
<br /> RATA FROCI SSINC I Cs..N i.'"IM.
<br /> I#..C).IM)X 527
<br /> PARA O MI',OA%Y M2-
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