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GENERAL INSMUCT]IONS-
<br />1, One FO "11" shall be completed for each tank for all NEW PL?It ` > , PERMYr CH (IIS, REMOVALS and/or any
<br />other TANK INFORMATION CHANGE
<br />1 This form should be completed by either the P13RMIT APPLICIM or the LOCAL AGINCY UNDFRQJ,OUNDTANK
<br />INSP R
<br />3. Please type or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are making 3 copies,
<br />l 'Sark an (X) in the I ox,, ext to the item that best describes the reason the form is being completed.
<br />at.•t ., x I d. to be f J icy name where the tank is installed.
<br />K. 'IAPB I)?�at;1C IxI llllw ALL IIS UNKNOWN d SO SPEc3FY
<br />A. Indicate owners tank l . If there is a tank number that is used by the owner to identify the tank (ex. AB70789),
<br />B, Indicate the; name of the company that manufactured the tank (ex, ACME TANK MFG).
<br />(1 indicate the year the tank was installed (ex, 1957).
<br />1), Indicate the tank capacity in gado (ex. 25,000 or 10,000 etc.):'
<br />11. TANK CON119M.
<br />A, I. If MOTOR VEHICLE MEI,, check box 1 and complete items B & C.
<br />2: If not MOTOR V1;F-1i(il;E FUE .., cheek the appropriate box in section A and complete items I1 & D.
<br />B, Check the appropriate box.
<br />C, Check the type of MO`FORVEHICL E, MEL (if box l 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 bore I is NOT checked in A.
<br />11L TANK C l iJ . ON - MARKQNE YITM ONLY IN BOXx,,11, C & D
<br />1. Check only one item in TYPE OFSYSTEM,TANK MATERIAL, I -.I.,"RI )11 LINING and CORROSION PROTEC110ia. ,
<br />1 If UIIIER, print in the space provided.
<br />M PIPING 1NM "170
<br />1: Circle A if above ground; circle U if underground; and circle both if applicable.
<br />1 If UNKNOWN, N, circle, K if OTHER, print in space provided,
<br />3, Indicate the LEAK DF,-I'CM- ON systern(s) used to comply with the monitoring requirement for the piping,
<br />V. TANK LEAK )I:° b C)
<br />1, Indicate the LPAK DE-1i ON system(s) used to comply with the monitoring requirements for the tank.
<br />Vt. INK)RMAIION ONTANK PERMANHVILY C1 1SED IN PIAM?
<br />1. FS-IIMA'ITD .4'113 sl" US 17 - Mt NIl."L %YPAR (.Ianuary; 1988 car 0I/88).
<br />2. ESITMATED C? 7AMITI"Y of HAZARDOUS SUBSTANCE remaining in the tank (in (gallons).
<br />3, WAS TANK ILL, 1) WWI I E,RT MATERIA,? Check 'Yes' or `NO'.
<br />APPI.,I£ mr MUSr SIGN AND D I1,? 11Ili FORM AS IMHCATED
<br />IN,'��FRUCIION FORHIP, LOCAL AGENCIES
<br />The state: underground storage tank identiiacA•.n number is composed f the two digit county number, tttelthrec digit,; jurisdiction' �,,d
<br />number, the six digit facility number and the six digit tank. number. The county and jurisdiction numbers are predetermined ane)
<br />can be obtained by calling the State Board (91.6)739-2421. The facility number roust 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 Stag: Board to assign the tank number, please leave it blank.
<br />rr i °IIl3 PXSPONSEBHrlY 011717113 LOCAL AGI. 'II T INSPIX.'IS 'l Ill? FACILTrY TO VERIFY 1111.1
<br />ACCURACY OF ITIE INFORNIN110N. TIIE LOCAL AGENCY IS RESPONSIBLE 'IT E; "YMPLITITON OF'ITIL
<br />'LOCAL AGrWCY USE ONLY0 INFORMAIION BOX AND FOR FORWARDING ONE FORM 'V AND 'S()C. `fla y
<br />R)-13'(s) TOTI1 LLO G ADDRESS.
<br />� t
<br />�rF
<br />RNI
<br />C/o smymm
<br />P.O. BOX 527
<br />PARAMOUNr, (A WM
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