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TNST' J('I1C)N5 FOR COMPLITFING I "13" <br /> 1. One FORM"I3"shall be completed for each tank for all NW PI:a . -,Pimmir"cHANOxifs, RFMOVAIS and/or any <br /> other'17ANK INFORTAK110N C1T NGF. <br /> 2, This form should be completed by either the I' I'I' PLIC. 'For the LOCAL AGFbKY UNDERGROUNI)TANK <br /> ISI"ILC;T'C3I . <br /> . Please type or print clearly all requested information. <br /> 4, Use a hard point writing instrument,you are snaking 3 copies. <br /> TOP OF FORM.M . ' ONLY ONE EI'T.i " _ <br /> l: Mark an (X) in the box next:to the 'stew that best describes the reason the form is being completed. <br /> 1 Indicate the I?La'A oa°Facility name where the tank is installed, <br /> L TANK I):'RIFTION-COMPLFFEI ALL I"t`Ii1 - IF UNKNOWN-SC)S'T'H?.017 <br /> A, Indicate owners tank 11)# -If thea is a tank number that is used by the owner to identify the tank (ex.A1370789). <br /> . Indicate the, mane of the company that manufactured the lank(ex.ilC E"LANK MFG.). <br /> CC. Indicate the year the tank ww installed(ex. 1987). <br /> i). Indicate the tank capacity in gallons(ex. 23,NX)or 10,M)etc.). <br /> H. '17ANK(DIS I'I? I'S <br /> A. 1. If MOTOR 41a11CCL,I FUEL,,check box 1 and complete items B& C: <br /> 2.If not muroR vi'1IICLE FUEL,check the appropriate box in section A and complete:items 13& Z). <br /> LT. Check the appropriate box. <br /> C. Check the:type of MOTOR VEHICLE FUEL(ifbox 1 is checked in A). <br /> T). print The chemical name of the hazardous sul)starice stored in the tank and the C A.S. . (Chemical Abstract Service <br /> naanber), if box 1 is NOT checked in A, <br /> Ill. TANK OONSS.` UC`1`ION-MAIM ONE r'Em ONLY IN BOX A,13,C.&I) <br /> L Check only one item m"I YPE3 OF SVSTEM,'T`ANK Mal'I'ERIAI,, i."vI'FIRIOR LINING and CORROSION PROTE0,10'.4. <br /> 2. if OTHER,print in the space;provided, <br /> IV. PIPING INIX)C I TTGt <br /> 1. Circle A if above ground,circle U if underground;and circle both if applicable. <br /> 2. If Ci41C"®COWN sac 1c; or if fi3°I`HER,'print in space provided. <br /> 3. Indicate the LEAK T E11"C T'1ON system(s) used to comply with the monitoring requirement for the piping. <br /> TANK E,I IC DE114CIlON <br /> 1. Indicate the LEAR T1FT (.'I ION systean(s) used to comply with the monitoring requirements for the tank. <br /> L VT. INFORfouvriON ON TANK Tai RMANEPd Y CLOSPI)IN PLACT, <br /> 1. T S PI11ATED DATF'LAST USED- C}:aV'I i/yEAi2 (January, 1988 or 01/88), <br /> 2. a1T T'ilfia"ai I�) C7L:ANITFY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS Tt%NK FILLED WITH INERT KMA'II✓f2IAL?Check'Yes'or'NO'.. <br /> APPII( T' S•I'SIG AND 3)o1'I1t'J11E FORM AS INDION11RD, <br /> INSFRU(711C)N FO TI T;LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the Mo digit county number,the three digit jurisdiction <br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling tlae State Board (9;16)739-2421.. The facility number anust be the same as shown in form "A". The <br /> tank number may b€ aassigned by the local agency; however, this number wrest be numerical and cannot contain an alphabet. if <br /> the Kral agency prefers the State Board to assign the tank number,please leave it blank. <br /> rF ISWE Ei ICI SP0 SIB I T"t' 017 T'IIE?LOC, I,AC { "II T'[ ISI E °I I9I � C°.I[: I C) 'RIF 'FITH <br /> C'C'[I C° OF I'ITE It"TFO '70N. 'ITIF LOO C'ITNC`Y IS II SP NSIBLIp FO "71E tCOMPI U11O 1 OF"I HE <br /> 'I.C)C, T.AGENCY U,4i ONLY'INPoimsnohi PA)x AN6 FORI FORWARDING ONE FORM" AND ASSOCIYVIE'D <br /> Est) -B-(s)T0 TIM}`C)T.I O I iG ADDRESS. <br /> SVVFE OF CALIFORNIA <br /> a i `TT?w 'I T;ICRESOURON C"CT TIRO ARI) <br /> C/o sm.finT.S. <br /> P.0,13O 527 <br /> PARAMOUNI',CA 90723 <br /> r <br /> ; �,, z <br /> 1 <br />