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[Idf; I`ICt.TC' PIONS FOR C;C) . .:1I CI *1P
<br />GENERAL IN,;;MUC11ON',1x
<br />1. One 1°tJRM "%3" shall be completed for each tank for all NEW PERIWM, PERmI ° CHANGES, S, II C)V S and/or any
<br />other TANK INFORMAMON1
<br />2, This form should be completed by either the PERWr APPLICAW or the LOCAL AGENCY UNDER( 5()Ii ° TANK
<br />S
<br />3. Please type or print clearly ail requested information.
<br />4a Use a hard point -writing instrument, you are **raking 3 copies.
<br />TOP OF MRNE *MRK, ONLY ONE
<br />I. dark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />2. Indicate the ` name where the tank is installed. 1,41-.1 .�a . ii,.;1,
<br />I. TANK Tai It 16 -m' 3 � ,1?'IM All, l]3?& - lig UNKNOWN - SO SPFX3.1
<br />A. Indicate owners tank ID # - If there is a tank umber that is used by the owner to identify the tank (ex. AB70759)..
<br />B. Indicate the name of theaxtmuiy-,h,4t rnanaafaetured the tank (ex. ACME °TAMC 1 11G'z.),
<br />C. Indicate the. year the tank s instaIG (ex, 1957), �
<br />1). Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.): ;
<br />1. TANK C O I" : I
<br />A. 1. If MOTOR VEHICLE I UEI,, check- box 1 and complete items B & C. "
<br />2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D.
<br />I3. Check the appropriate
<br />C. Check the type of MC1'TOk,, EHIC LE FUEL (if box 1 is checked in ft):
<br />D. Print the chemical name of the hazardous substance stored in the tank and the C:.A.S. . (Chemical Abstract Service
<br />number), if box 1 is NOT checked in A,
<br />III,. T C U ION _ MARK ONE 1.. ONLY IN BOX, 13, C & D
<br />1, Check only one item in TYPE OF SYSTEM. M. XNK Tvll TE,'RIAL, INTERIOR LINING and CORROSION PRO TEX711CJN.
<br />2. If 071TIER, print in the space prov=ided.
<br />TV. PIPING IN17ORMSITON
<br />I. Circle A if above ground; circle L7 if unde tired* and circle both if applicable.
<br />2. If UNKNOWN, circle, or if 071- EIZ, print in space provided.
<br />3. Indicate the LEAK D I"I C:'1' ON system(s) used to comply with the monitoring requirement for the Piping.
<br />V. TANK LEAK 1)111 C)
<br />1.. Indicate the LIQ. DEIT ON system(s) used to comply with, the monitoring requirements for the tank:
<br />V1. ORMA'110N ONTANK PfffANY.WfLY CIDMID IN PLACE
<br />L F STI "ITl) DATE LAST USED m ii1ONITI3/1 . R (January, 1988 or 01/99).
<br />2 ESHNIATED C UANITI"Y of HAZAiTDOUSSUBSTANCE remaining in the tank (eta Gallons),
<br />3 WAS TAN Fl l,LED WITH INERT MA'JFERIAI,,? Check 'Yes' or ' C)'.
<br />iArRLwAbfg,,MusrSI •' mm°Tiw, FORM AS ININCAMD.
<br />IN5MRUCI1ON FOR 311H LOCAL AGENCIES'
<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 th x digit tank number. The county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State Board (99.6)739-2421. The facility number must be the sauce as shown in form "A'. The
<br />tank number may be assigned by the local agency; however, this number must be numerical and earnest contain an alphabet. If
<br />the local agency prefers the State Board to assign the tank number, please Dave it blank.
<br />T ` IS THE S I311 Ir "M'I1 1`� Y "1' 1AT INSPECT I TML? FACIL< V ,,,, n . .t t
<br />ACCURACY C;Y OF TITE INPORMKIION. 71113 LOCAL AGENCY IS III-SPONS1131.1I FOR 171 C)MPIIq10N 011 "it I
<br />11,O(" AGE (1Y USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE MRM 'A' AND ASSOCINITID
<br />FORM 'Tr(s) X) 11113 F011,0WING
<br />C/o . ..1$ P: .
<br />DATA PROCMSING
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