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INSMUC71IONS FOR CC) I'L s PICT *'IFS
<br /> 1, One FORM"I3"shalt be completed for each tarok for all ., PER N, PERMrlCITANGUS, RF MOV I S and/or any
<br /> othe r TANK INFOR, 'IION CITIANGF?
<br /> 2. This form should be completed by either the P,. Tr. PPI ICAN.r or the LOCAL AGEN , UNDERGROUNDTANK
<br /> I SPEu`(TPOR.
<br /> 3. Please type or print clearly all requested information.
<br /> - 4. Use a hard point-warning instrument,you are making 3 copies.
<br /> TOP C)r IMM. 'MARK ONLY ONE TFT?
<br /> 1, Mark an(X) in the box next to the item that best describes the reason the form is being completed.
<br /> . Indicate the DLA or facility name where the tank is installed,
<br /> T. T TISC:RIP IO - 2MM I' tS `EMS
<br /> . -I UNKNOWN-, 'F,C71
<br /> AI Indicate owners tank II) #-If there is a tank number that is used by the owner to identify the tank(ex, 747789).
<br /> B. Indicate the mane of the company that manufactured the tank.(ex.ACME'I'AI`K MFG,),
<br /> C. Indicate the year the tank was installed(ex 1987).
<br /> 1). Ladicatc the tank capacity in gallons(ex.25,0o`l or 10,000 ctc.).
<br /> FF. TANK C°ON'11'sl `14
<br /> � . 1.. If MOI'(,...)R VI1,,11ICl,i FUFJ,,check box 1 and complete items B& C.
<br /> ?.If ren 4TFC7IZ VEINC:°LE ISL IT,check the appropriate box in section A and complete items Fi& 1),
<br /> EI. Check the appropriate box,
<br /> C, Check the, type of NNIC)`FOR VEHICT.F.FUEL(if box 1 is checked in A).
<br /> 1), Print the chemical name of the hazardous substance stared in thetankand the C,A.S. .(Chemical Abstract Service
<br /> number),if box 1 is Nar checked in A,
<br /> III. TANK CONST UMION-IMARK ONE 1711W ONLY TPS BOX A,B,C
<br /> 1. Check:only one item inTYPE OF SYS'TT;WFAiNK TMt TI,"R AL, INJE3RIOR LINING and CORROSION PROTFTCpIO .
<br /> 2. If OTHER,print in the space provided,
<br /> Fly. MING NFORMA'nO
<br /> I. Circle A if atxove ground; circle U if underground, and circle both if a'pplicable.
<br /> 2. If L NK-NO N,circle', or if 0 IIFR,print in space provided.
<br /> 3. Indicate the L 11K Df TI%Ca`ION'sy'stcm(s)used to comply with the monitoring requirement for the piping.
<br /> V, TANK L!�AK DF11fiCHON
<br /> 1. In ;cite elle I,FQ% I;C"i"IC)iv systern(s) used to comply with the monitoring requirements for the tank.
<br /> VI. INTF'C) `IO ON TANK PERMANFITMY CLOSED IN PIACI?
<br /> 1, F-511iV1A'I` D DATF IAST USED- ONUTi j't'EA (January, 11988 or 01/88).
<br /> 2, L,STIMA-11,I)Qtu<'1INTI'I'Y of HAZARDOUS SUBS'I'A CE remaining in the tank(in Gallons);
<br /> 1 WASTANK FILLED Wfl-11 IS EIrI'M-,,XT;FtlAL? Check'Yes'or'NO'.
<br /> ARpIJC.tkN`F MLJI;FSIGN AND 17NMz TII ?FORM .S INDIC ITID,
<br /> IRIS`rR JC'I'I0N pOR THE LOC 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 and the six digit tank number. Th:county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)739-2421. The facility number must be tine 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 containan alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank.
<br /> T1'I °1711;T 13SPONS11111,F1Y OF T`TTE?LOCAL ("sINGY 171 `1'1NSPE(.'1,S`ITIS F C;1F,M`10 VE F Y°nIE
<br /> CC'IT Cd Oil-ME MuRmAnoN. TIM IDCAL AGENCY IS ILHS'ONSIIFLIl FOR 17111 COMPLI: CyN OF Tfii,
<br /> 'LOCAL L GENC:'Y USE tlNLY'INFORMAMN BOX AND FOR IlOR '))I G ONE F * w AN. ASSOC I`f;17
<br /> IX,yRMW(s)1T)111E,FOMOWING T)131ZE S.
<br /> SI"tT"IT WNHIR RaSOURCItS COMMOL BOARD
<br /> C/o S: I.i I;.P.S.
<br /> DNI'A PROCM&SING ai Ilea;
<br /> PD.1IOX 527
<br /> P C3UNI°,C`. 90723
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