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W INS't'RUC11ONS FOR COM-PLEI ING FORM *11' 0 GFNFRAL INSTRUCtION& 1, One FORM 13" shall he completed for each tank for all NliW PERMTIN, REMOVALS and/or any other TANK 1NfT)RMNI'I0N CJIANGF- 2. This form should be completed by either the PERmrIAPPI.1CANI' or the LOCAL AGENCY UNDERGROUNDTANK INSPECTOR. 3, Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. -' I TOP OF FORM: 'MARK. ONLY` ONE Y11M" � I , -i . !"% 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA (y Facility name where the tank is installed. 1. TANK I)ILSCRWIION - C.OMPLUM AIA. TIEMS - IF UNKNOWN - SO SPECIFY. , z, A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). B. Indicate the name of the compvy that manufactured the tank (ex. ACME TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). H. TANK CON171WI'S A. 1. If MOTOR VEHICLE FUEL, check box I and complete items B & C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the " of MOTOR VEHICLE FUEL (if box I is checked in A). '4 D. Print the chemical name of the hazardous substance stored in the tank and the CA.S,#. (Chemical Abstract Ser"+re number), if, box 1 is NOT checked in A. 111. TANK (X)NS`1RUC1.7ION - MARK ONE rll�W ONLY IN BOX A, B, C & D I. Check only one item in TYPE OF SYSTEM, TANK MAJ 11RIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTIIER, print in the space provided, IV. PIPING INFORMN11ON 4 1. Circle A if above ground; circle U if underground; and Circle both if applicable. 2. If. UNKNOWN, circle; or if OTHER, print in space provided. 3. Indicate the LEAK Dl7IE.CnON system(s) used to comply with the monitoring requirement for the piping. V. TANK I.FAK D M,7X-'l7ON . '. i 1. Indicate the LEAK DI LECTION system(s) used to comply *ith the monitoring requirements for the tank. VL INFORMAIION ON TANK PERMANENnY CLOSED IN PLACE f:sA R(January.1988orGI/88). 2. ESTINIA1171) QUANI'ITY of HAZARDOUS.-SJU135FANCE remaining in the tank (in Gallons). 3. WAS TA;i(1 LLED WITH IN17XV MA1171RIAL? Check 'Yes or 'NO'. Appu(Aw MUST" SIGN AND D/VI'E TIJE FORM AS INDICNITID. uwritucnoN FORT11E LOCAL A60NCIES The state underground storage lank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form 'A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot containan alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. rr is Tim mspoNsimirry OF 'n i I,, ix)(Atl, AGENCY "wi, INsPucm Tim FAclury TO vERnry ilm ACCURACY OF 'nil! INFORMA] ION, qDCALAGENCY USE ONLY' 1NMl0AAJION'lX)XAND FOR FORWARDING ONE FORM "A!AND ASSOC1A7rFD FORM -Ir(s) -170 11H, FOLIA )WING ADDRI?SS. 51'A7]'E OF CAIJFORNIA S -FATE, WNJVR RISOURCES CONTROL BOARD CIO &W.F-E-*P.S. DATA PROCIrSSING CE;NMillt P.O. BOX 527 PARAMOTIN'T', (A %M3 0 J " . , . -j , I -,* I :' I ,....'i-. i -1 6