|
a, ' s><.. xc'w'0e ,3r,.
<br />IU
<br />f�situ
<br />1N,'5l`ICUC 711ONS FOR C"OMP111I'I G I 32I �I "
<br />(mNo E. s rRLXT1"IC1 1S
<br />1. One FOWNI "B" shall be completed for each tank for all N17W PERNIMS, PERMI'170HANGES, REMOVA1.13 and/or any
<br />otherTANK. IISFOR ') ON CHANGE
<br />" NGE
<br />2. This £carni should be completed by either the PERM17I" PPLICANP or the LOCAL AGENCY UNDERGROUND "IANK
<br />INSPI;C:rOR.
<br />3. Please type or print clearly all requested inforntation.
<br />4. Use a hard point WoUng instz°s x ee , you are making 3 copies,
<br />'MP OF FO "MARK ONLY ONE Mt �
<br />1. Mark an (:C) in the box next to the item that hest: describes the reason the form is being completed. 1
<br />2. Irrdicatu tine I)1X A orfFecilfty name where the tank is installed.
<br />I. rANK I3 SCa 1`104 - oM'Pi. ni Am "IwS - Er UNKNOWN - SO SI" :r IFIL
<br />A. Indicate owners tank 111 # - If then: is a tank number that is used by the owner to identify the tank (ex. AI370789).
<br />B. Indicate the name of the company that manufactured the tank (ex. AC E TANK SSI -Ci.).
<br />C. Indicate the year the tank was installed (ex. 1957).
<br />D. Indicate the tank capacity in gallons (ex. 2.5,000 or 10,tXXa etc.).
<br />IIx TANK C ON'I"Ix IN
<br />A. 1, If MO 1'0R VEHICLE LE I'UEL, check box "! aand complete items I3 & C.
<br />—1f not, C)'1OR VEHICLE, FUEL, check the appropriate boss in section A and complete items 13 & IS.
<br />kk
<br />11 C`ie&k ile'rippropnut box.
<br />C. Check the type of laf1C?'I`OR VEHICLE MEL (if bass 1. is checked in A).
<br />D. Print the chemical name of the hazardous substance stared in the tank: and the C.A,..S. . (Chemical Abstract Service
<br />number), if box 1. is NOTchocked in A.
<br />III. 'LANK C0NS`1 IZCI(:'110N - MARK ON1:: num ONLY IN BOX, As 13, Cd & I)
<br />L Chock only one item ntTYPE OF SYS'ITUM,TANK MATERIAL, Ihl`pERTOR LII'al'I'NGx and CORROSION hI7C TE'C'1'TOM
<br />2. If C3'I'HER, print in the space provided.
<br />IV. PIPING INFO A`fION
<br />I. Circle A if above ground, circle U if underground; and circle birth if applicable,
<br />2. If UNKNOWN, circle; or if C)'f`HEIZ, print in space provided.
<br />3. Indicate the: LEAK I)t:"1'ECTION systems) used to comply with the monitoring requirement for the piping.
<br />V. TANK I.Ix,AK 13HMC"ITC)N
<br />L' Indicate the LEAK Iii ITC71'1ON systena(s) used to comply with the monitoring requirements for the tank.
<br />VL INFORMA7n0N ONTANK ICER ANI:AN°t x CLOSED IN PI AC I?
<br />1. ESI`IMATED DtVI`T. i.A,57' USEM - MOIN'"I'II/Y R (January, 1988 or 01/5£3).
<br />2. F, 'I1D QUA.,NrITY of HAZARDOUS SUBSTANCE remaining in the'tank (in Gallons).
<br />3. WAS TANK ktILL1,13 W111I INE>I(p > 3'iTRIAL,? Check 'Yes' or 'NO'.
<br />.AI P11 " S I" Sl(;N AND DA n.t "I II? 1URM AS INDIC A'IED.
<br />e . UCI`It3N FOR THE LOCAL AGFNC 1aS
<br />The state underground storage tank identification number is composed of the two 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 Board (916)739-9-421. 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 comafna an alphabet. If
<br />the local agency prefers the State Board to :assign the tank number, please leave it blank.
<br />rr is mE RESW)NSII31I OF ITIIE I.C)CAL ACiI C:Y `I "I�.I' INSPE( ..1',%'I II3 FAC,7LTCY TO VERUZY11TE
<br />A ` RA '. OF "I II? INFORM)VI70N. T1IEI LOCAL AGENCY IS RESPONSIBLE FOR THE COMPIE11ON C)It °ITIS,
<br />'LOCAL AGENCY USF ONLY" UVORMA7170N BOX ANIS IK7 IX)RWARDING ONE FOAM "A" AND A SOCIA'I13I7
<br />IOJ "I3"(s) 'I`C) THE, FOLLOWING ADDRESS.
<br />A`1E OF CALIFORNIA
<br />5 I "T I s A'I EI.IE R ',1 10 R(, l l,y CON 17ROL BOARD
<br />DA7 A PROC7F-&SING C fWI"E IC
<br />I°,0. BOX 527
<br />PARAMOUNp, CA
<br />
|