|
a e
<br />Il' SIRUC'IIOS FOR I;OMP1.1117PsC1 110II ' a
<br />i.
<br />GENERAL INITFRUMTONS,_.
<br />L One FORM T" shall be completed for each tank for all NFW PERMIT -S, VE "1' C GF -S, REMOV AUS and/or any
<br />2, 1"his form, should be completed by either the i'13 I°1` rAPPI.1C'.a'ANI" dr the L .3(° ° AGENCY ITNI` ERGRCiUND TAN
<br />SPI.FX113R.
<br />3. Please type or print clearly all requested information.
<br />A. Use a hard point writing instrument. you are making 3 copied
<br />°I` ) OF 17ORM: ',MARK ONLY ONE 1"171
<br />I. Mark an (X) in the box next to the iters that gest describes the reason the form is being completed.
<br />2. "' Indicate the DBA or Facility name where the tank is installed.
<br />1, TANK 131.35 y IIa11O - CX)MPIZIli ALL I"IEMS - [IF UNKNOWN - SO IaP1W,I1
<br />A.. Indicate owners, tank IL) - If there is a tank number that is used by the owner to identify the stank (ex AB70789).
<br />I3. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG.).
<br />C. , Indicate the year the tank was installed (ex I987),
<br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,f0 are),
<br />11. TANK 'CINI"i3I3'1'S
<br />Al 1. If MOTOR VE11I01," DUEL, check box I and complete items 11 & C;;.
<br />2. if not M01't R A%I111CIT FUEL, cheek the appropriate box in section r'A and complete `stems 13 & D:
<br />13.' Check the, appropriate; box,
<br />C:, Check the type of MOTOR V131I1C LF I'1 EL (if box l is checked in ).
<br />II,' Print the chemical name of the hazardous substance stored in the tank arses the C; A.S4, (C'he'mical FAbstrxact, Senice
<br />number'), if box I is l'=d(' T checked in A.
<br />111. TANK CPf1TI41"I 13C" 101 H MARK ONE TITM ONLY IN BOX A, Iia C3 & D
<br />I. Check only one item in 'I"YPE OF SYS"I`I,,M, T AN M A'1'I.RI,AL., INFI�1;' IOR LINING and C;C3RROSIC` N PROTECTION,2. ' If (i"1'11i , prism in the space provided.
<br />IV, PIPING 1NJX)RMXrI0N
<br />1. Circle A if above ground; circle U if underground; and circle both if applicable.
<br />2. If UNKNOWN, circle; or if OTHER, print in space provided.
<br />3. Indicate the LEAK DEE TECTION sy;tem(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LVAK DRUIX7.11ON
<br />I, Indicate the LFAK LSI„I7",C"rI0N system(s) used to comply with the monitoring requirements for the tank.
<br />V1, 1 11'312 e J10N ON "HANK PF " NE*, I1, C10SL<11 TSI PIACI;',
<br />1, I;S'1IMAI 1) I?'r.A11” LAST" USED w M(.siy OI/"YI. AR (January, 1988 or (11/138).
<br />2 I,4 i'I2MAT ) t UtAIVTr Y of H AV ARDOUS SUBS'1"LANCE remaining in the tank (in Gallons),
<br />3, WAS TANK H I,I,13 WI'f II I;vlai$1 MA l'E'RI L? Check 'Yes` or NO',
<br />The 'state underground storage tank identification member is composed of the modigit county number, the three digit jurisdiction
<br />nurnher, the six digit facility number and the six dight tattle number. The county and jurisdiction numbers are predetermined and
<br />call be obtained by calling the State Board (916)739-2421, The facility number must be the same as shown in form "A". 'file:
<br />tank number may be assigned by the Beal agency, however, this number must be numerical and cannot contain an alphabet. If
<br />the local agency prefers the Stage I3a)ar # to assign the tank number, please leave it blank,
<br />T1" IS 11IR RUSPONS1,1311.117Y OF 11111 LOCAL AGENCY Y 11VVF I SP1X11'S 111I1 1F CILrI"'1" TO V1"1RI Y °1'1113
<br />ACCURACT 01F T1I1 INFORMN.110N. 111H I .MAL AGENCY IS RESPONSIBLE 1k)R31111 COMPIZ110N OF 11113
<br />'LOCAL GENC"''7' USM ONLY" IN13CIii '1"100 BOX ANT) FOR IX)RWARDING ONE FORM *A7 AND W)CI IFID
<br />3£)R "Ir(s) -1`0 -111H R3110W Ca-ADDR zJ%S.
<br />DATA PRO(M SI G C>1 NrER,
<br />POC 13OX 527 gre
<br />
|