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INSIRUC310 , NS FOR COMPLIT11N PRIA *W
<br />1, One CORM "I3" shall be completed for each tank for all NEW TIS ., ]PERMrr nI CIT3.S, REMOVAI.S and/or any
<br />other TANK INFORMATION (31ANGE
<br />1 This forst should be completed by either the PERMH APP1,10 or the LOCAL AGENCY UNDTIRGROUNDTANK
<br />SI"I
<br />3. Please type or print clearly all.requested information
<br />4. Use a hard point writing instrument, you are staking 3 copies.
<br />,.
<br />1, Mark an (X) in the; box next to the item that best describes the reason the form is being completed.
<br />2. Indicate thaw sty name where the tank is installed.
<br />1. TANK I)T C,RIF11O .. C04*
<br />.ice sit . rirms - IlE uNKNowN - So spEcwyr i
<br />A. Indicate owners tank Iii # m If there 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. ACME TANK MFG,).
<br />C. Indicate the year the tank was Inst sled (ex. 1987).
<br />D, Indicate the tank capacity in gallon 25,000 or 10,000 es e
<br />11. TANK CONT12M,
<br />A 1. If MOTOR VEHICLE UE, cheek box'1 and complete items T3 & C.
<br />2. If not imii3TOR VEHICLE FUEL, check the appropriate box in section A and complete items B D.
<br />Tl. Check ck the appropriate x.
<br />C;, Check the t of MOTs) ERIC I.E. FUEL (if box 1 is checked in A).
<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. TANK C".0 NS UCII CTlv1- MARK. ONE TI724 ONLY TX)X A, 13, C: & 1)
<br />1, Check only one item in TYPE OF SYSTEM,TA'*T4K,MATERIAL, INTERIOR LINING and CORROSION PROTECTION,
<br />2. If i3'I`HER, print in the space provided.
<br />1, Circle A if above ground; circle U if underground; and circle both if applicable,
<br />2. If UNKNOWN, circle; or if C)°1"HER, print in spare: provided.
<br />3, Indicate the LIAK DETECTION system(s) usqcin to comply with the monitoring requirement, for the piping.
<br />TM
<br />V. TANK LEAK DUI13MION
<br />1. Indicate the LEAK DF,i`I3CTION system(s) used to comply with the monitoring requirements for the tank.
<br />1, ESTIMA11.1) DATI' 1AST [ SED - aMOINi"I.' I/YEA Z (January, 1988 or 01/89).
<br />2ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE E remaining in the tasty (in Gallons), ;
<br />3, WAS TANK PILLED WITH INERTMATERIAL? Check 'Yes' or `NO',
<br />WAUMMUST S163NAND DATE T1111 FORM A.S ININCAU91
<br />IriSM UC'I'ION FOR "C T131. , 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 aud["t'k*Ajq, digit tank number. The county and jurisdictions numbers are predetermined and
<br />can be obtained by calling the State Board (916)739-2.921. The facility number must be the: same as shown in forma "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 tri to assign the tank number, please leave it blank.
<br />. 171` 1S "I IF RESPONSUMIXFY OF 11 & A1,Ak4WCY 11 TAT INSPEcxs -n u, IrA Cr11 n -y To VERIFYI, Ilk
<br />ACCURACY OF 171 aA3.10N. IIIE LOCA[, AGENCY IS RaSPONSIBIX FOR THE co I,Ia"1' 6k 60 " ija
<br />*LOCAL ENCY USE ONLYO 1[NFORMA17ON BOX AND F RARDIN 's ONE FO "A" AND 'ITID
<br />IAC "B"(s) TO 11113 FOIJDWING I7 .S j
<br />[' T'E WATER RESOURCIISCONrikbi. I
<br />C/o S. . ,RP.S
<br />P.O. BOX S 7
<br />PARAMOUNT, CA e
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