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INSPRUCHONS Ik)R COMPI<I, G -Ir
<br /> 1. Nese L'C7RM "LI"shall be completed for each tank for all NEW PFR 'S,I'I:RMI'1 C HA GFt , RFMOVAIS and/or any
<br /> other'I'A O /VI1O CIIA G
<br /> 2. 'This form should be completed by either the PT,R Tr APPI CANT'car the LOCAL AGENC Y UNDERGROUND'I'ANK
<br /> LAST 1 I£.
<br /> 3, Tease type or print clearly all requested informations.
<br /> 4. Use a hard point writing instrument you are making 3 copies.
<br /> OF FORM. "P ARK ONLY C1NI?r1I? '
<br /> 1. Mark an (X) in the box neat to the hem that best describes the reason the P"c>rm is being completed.
<br /> .
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> L 'I'ANK sCRIVN ION--COMPLUFF ALLFt ESS.. IF UNKNOWN-So PECI
<br /> A. indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.A 374 789).
<br /> Ft. Indicate the name,of the company that Manufact red the tank(ex.ACMF1°I'AN MFG.).
<br /> G.).
<br /> C. Indicate the year the tank, was installed (ex 1987).
<br /> I), Indicate the tank capacity in gallons(cx.2-5,000 or'14,0etc.),
<br /> A. 1, If Si40'I'OR VFIIICI.'s,FUEL,check box i and complete items B& C,
<br /> 2.If not MO'FOR VEHICIJS FUFIL,check the appropriate box in section A and complete items B& D.
<br /> B, Check the appropriate box.
<br /> C:. Check the type of y,101'CIIZ VEHICLE 1`1JEL(if box I is checked in A),
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C ,S. .(Chemical Abstract Service
<br /> nurnber), if box 1 is_NO'Ve°hecked in A.
<br /> 111. 'FANK C Ohp;, RUC IO -MARK ONE I7.11I ONLY IN BOX FI,C&I
<br /> 1. Check only one iters in'l-Y'E CF'SYS` FM,HANK MA1,1' T>, Itif`F;I2IOR LINING and CORROSION PROTECTION.
<br /> 2. It C:)"1'1lli;R,print in the space provided,
<br /> IV. PIPING INFORMATION
<br /> 1. Circle A if aboveground;circle U if underground; and circle both if applicable.
<br /> ?. IfUNKNOWN, c acaa; or of 011114R,print in space provided,
<br /> 3. Indicate the LEAK DF-I-f r'HON system(s)used to comply with the monitoring requirement for the piping,
<br /> V. TANK I.MK DINEC ITC7
<br /> 1. Indicate the LF AK DE`1' C;.hl N sxstem(s)used to comply with the monitoring requirements for the tank.
<br /> VI. I FO A'I'ON ON'PANK PERMANENFIMCLOSED SED IN PI f l?
<br /> 1. ES11MA'I'K17 (D"'�Ay`i'L3 L.ASI'USI:�D«11JON, 111/YEA (January, 19I18 or 01/89).
<br /> 2. ESC'INJA'I'1'I� R;ANR'I�Y of TLAZARDOUS SUBS'I'rANCE remaining in the tank(in Gallons).
<br /> 3. AS'FANK FILLED wrni INLF1I MA'I'ERI.AL? Chuck 'Yes' or'NO'.
<br /> APPI I(YiNr ,;;I'SICK AND DiVIE*111H IDRM AS I DICNI",0.
<br /> I`3`III (TrIC3 Fa`OR'ITIE LOCAL AGENCIES
<br /> 'T'he state underground storage tank identification number is composed of the two digit county number,the three digit jurisdictions
<br /> number, the six digit facility numts cr and the six digit tank number, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Bogard (9z6)739-2421.. 'i'he facility number must be the same as shown in form"A". 'I'he
<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 Board to assign the tank number,please leave it blank.
<br /> I''IS'HIE?RldPONSIBIIXFY 017 TIIH LOCAL AGEWY 11INFINSPINTIN17W rAC11.111' 'M VERIFY'IEE
<br /> ACCIIRA(I 'C I'"IIIIo INI�O )V.FIO . 'ITIS L O(AI,AGENCY IS RESPONSWILE��FO '11111 C:C?�IPLE,n N OF"1'IIT.
<br /> 'LOC AL AGfTN '"USE ON INFO NF IO IT FOR OR]FOR ARDING O ICOR A' S' C:IN111,I)
<br /> FO W(s)'I°t)'ITIF?il6i.,LOWING,ADDRESS.
<br /> rXFE OF CALIFORNIA
<br /> IA
<br /> 91W!T?WNIER RF— URCHSI I`CC)I BOARD
<br /> C/o S,W.TL Fs.
<br /> DNFA 1R(.X:iSSI G (71WHER
<br /> ® P.OW)X 527
<br /> PARA OUt I',(".ft 90723
<br />
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