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INS17RUC110M FOR COMPLVITNG FORM"W <br /> 1. One FO "I$"shall be completed for each tank for all NEW PE 1S,PERMIT CIIANGEMOVAISand/or any <br /> otherTANK INFORMATION CIIANG1 M <br /> 2 This form should be completed by either the PL 1r APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument;you are making copies.' <br /> P OF 1 ONLY ONF M4201' <br /> 1. Mark an(X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK IAF' 1ON-COMPIFIE All,MMS&? -IF UNMOWN-.SO SPFCHTY <br /> A. , Indicate owners tank ID#-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.AC"ImRI~TANK MFG.). <br /> C. Indicate the year the tank was installed(ex."1987). <br /> DIndicate'.the tank capacity in gallons 25,000 or 10,000etc.). <br /> II. 'I'AN IV I'S <br /> A. 1. If Mt?'I`OIZ VEHICLE 1AJEI„check box I and complete items B &C. <br /> 2. If not MOTOR VEHICLE FUE,L,check the appropriate box in section A and complete items TI&D <br /> B. "Check the appropriate box: <br /> C. Check the type of MOTOR VEHICLE FUEL(if boxI is checked in A). <br /> D. Print the,chemical'name of the hazardous substance stored in the tank and the C;.A.S4.,(Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> III. TANK CONN UC`11ON-MARK O :1 rIVM ONI<Y IN PDX A,A C>&1°2 <br /> 1. Check only one item inTYPE OF SYSTEM,"I"ANK MATERIAL,INTI"I;ItIO LINI G and CORROSION P32OTEC"rION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING I TION <br /> 1. Circle A if above ground;circle U if underground; and circle Both if applicable. <br /> 2. If UNKNOWN,circle;or if OTIIEI?,print in space provided. <br /> 3. Indicate the LEAK DEIMC"`I°ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHIIiCnON <br /> 1. Indicate the LEAK DEIT-KTION system(s)used to comply with the monitoring requirements for the tank. <br /> 'CJI. INFORMATION OIe3 TANK PERMANFNILY CLOSED IN PI.ACM <br /> 1. ESTIMATED DATE LA9I'USED-MO I/Y It(January, 1.988 or 01f88). <br /> 2. ESTIMATED QUAN'I'ITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WMI INE I` A'I"ERIA" Check'Yes'or'NO', <br /> APPI.IcAw musr sI N AND DATF,'11m FoRm As micAmm, <br /> ITC CON FOR IIIE LOCAL ACi£tNC;II?S <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.-The county and;jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in fortis "A". The <br /> tank number may be assigned by the local agency; however, this number roust 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 /> IT IS`17113,RESPONSIBUMOF 77111 I.oC.AL AGINC Y'l ISS INSPE S TUY!FACIIXI°Y"TO VFRIFYTHE <br /> ACCURACY OF'1 .I TION. '111131,OC°AL AGENCYIS ONSIIILE I?Olt'1 IE C;OMPIHI°ION OF'11IR <br /> "I ACYI USE, ONL`*1 ?OR TION I FORWARDING ONE FOR 'A" D ASSO C>IA"1 -1I) <br /> FORM'B'(s)TO <br /> '17141H,FOLLOWING ADD . <br /> ATE OF , J1?ORNI <br /> 9I'JV1'?° A'1."I.R Iiia" URC:IN C:ON'I'PCII BOARD <br /> C/o& ..w.i ps. <br /> IiIA'I"A Pii. ;5~rall' i am <br /> P.O.BOX 527 <br /> P OUN. ,CA 99M <br />