|
qx .' kuda-e; bs
<br /> TNS`.I2LIC;I'IC)1 S FOR C O PI.JTPING FOR 'Ili
<br /> GENERAL I �I'RUC'I'IONS.
<br /> 1. One FORM "11"shall be completed for each lark for all NEW E RMI' ,PERM11"C",IIAGEN, RIUMOVI and oaany`
<br /> other TANK INTiORMA11f) l Ci"III NGF-
<br /> 2. 'I'his form should be completed by either the I1FRmrrAPP1X7VW or the LOCAL Asli C Id DI?I2C R0TJND`I"el l
<br /> 3. Please type or print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> 'MP OF I Ri :WARK ONLY ONE Pili "
<br /> 1. Mark an (X) in the box next to the henry that:best€3cscribc;s the reasons the form is being completed,
<br /> 2. Indicate,the,T.)F A,or Faeihty name where the tank is installed,
<br /> 1. IANK RIV170N m C OMPISE,Ili ALL 1711IMS-TP CJ OWN-So:)SPfW IT5'
<br /> , Indicate ownem tank II) # d If there is a tank number that is used by the owner to identify the tank(ex.A1370799).
<br /> B. Indicate the name of the company that masnufactured the tank(ex.ACME.I`ANK Ml-(.i).
<br /> C. Indicate the year the tank-was installed (ex. 11E17).
<br /> I). Indicate the tank capacity in gallons(ex.2,5,(M or 10,000 etc.).`
<br /> A, L If M01'OlL VEHICLE FEU;La,check box 1 a d iornptete items L3 & C.
<br /> 1 If not N"C`'FOR VIMIC::1 F,Ful-1,,check the appropriate box in section A and c€mpletc items 1.1 & 1),
<br /> 13. Check the appropriate'box,
<br /> C;. Check the type of M01'O V1:HIC.L,E FU11,(if box I is checked in)}
<br /> D. Print the chemical name of the hazardous substance stored in the tank and tate C,A.S_#. (Chemical Abstract Service
<br /> number),i1 box z is Nc1'I'€heck d in A.
<br /> III. 'TANK C ONS`i'RUC711O -MARK C) I rITW ONLY IN BOX A,D,C;&I3
<br /> 1. Check only one item. in'I"YPE C11;°liYS"FE 1,'l'A;N IwtXIIIF AI,, WFFE3'sIf7R T;[NTrti'G and C1C7I2TIOf%tB3N PRO'FF,C.T'l0N,
<br /> 2. If 01111>.1Z, print in the space provided.
<br /> IV. PIPING INK)RM/VI70N
<br /> 1. Circle A if alcove ground; circle U if urtdergroundand circle both if applicable
<br /> 2. If UNKNOWN,WN,circle; or if£J'€'IIER,print in space pr vided,
<br /> 3. Indicate the LEAK used to comply with the monitoring requirement for the piping.
<br /> V. 'I` NK LIAK II11,111."5TC)hl
<br /> 1.. Indicate the LEA p9L"I33t 'EC) systerr(s) used to coo ply Aith the monitoring requirements for the tank:
<br /> VI: I le ) `I10N C3 'I'A PE1I NI:!`INI`,Y CLOSED IN PLACE
<br /> 1. a5rim ia'D IwI I: I. gr C.ISE D-MCJ"e'tII fYAR(January, 9€188 or 01/88).
<br /> 2. F.srim/VFE D QUAN"I'117y of I IAZ,t1I :J£JUS SUM s'.1 ANC E, remaining in the tank(in-C.iallons);
<br /> 3. WAS TANK 17111.11) AL'CIIi INI.f r SIr3` FRIfi1L;? Check'Yes'or'NO'.
<br /> I'PucANI'mxj s r SICihd AND D A'1.1VI'II E ITORM AS INDI( I`I:?II;
<br /> I SI'RUC"ITT Ik)R'I"IIE LOCAL AGE C;IIS
<br /> 'I'bc state under ound 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. 'l'he county and jurisdiction numbers, are predetermined and
<br /> can be obtained by calling the State Board (916)739w2421. 'I'iae facility number must be the same as shown in fi),nn "A'% 'I'itc
<br /> tank number may be assigned by the local <agency: however, this number rust be numerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> I'I'IMS 1I1E RI SIaC313SEI3[.,IIA C)1 "IIIb I >C I.atCLII C `l I I'E �Ixl f:[S IIiI:;I ;II CI 4' IC) I:ECII ''I LIp?
<br /> ACvC U (TY C)1$111E IN1101 )ION. '111E Y,.,)C: I,AGENCY IS RESI'tBI MI31 :'s]FOR'III I C OMPLE°11ON Of'"Alli
<br /> 'LOCAL.GI.?IY£Y USE ONLY'1N1DRMA'F10N BOX.AND FOR IzC R AR 9I: CE ONE IDR "A'AND eAW)C;IA7[I:3I3
<br /> IAC) W(s)`170'171U FOLLOWING s DDRER&
<br /> SPNI1:OF C ALIIr()R Id1
<br /> f,?'A'I It,_11W)V°Ia.R P11"N,Ctt,fia,C"pf,r IyN,I'R£.tr,FW�.A LIt3
<br /> CV
<br /> PARAMOUNT,(A Sat`72,3
<br />
|