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<br /> 1N,Tr U(.,.'0N,S FOR CSG MPI.1?'ok) m 11y
<br /> GENERAL 1NSf' U('I'10 S.
<br /> 1. t ttc Ia£111.,r1 °11r, ;a,.Elt rr rl ,:.,.t t „ innk fa,, NF, x X11 E ,PI:?1G I'T C'I] NGFS, REMO AUS and/or any
<br /> hi ..>,:,., ghoul¢ be a°om b au.:a by 6t,€ e PF TF PI 1C.. '1'or the LOCAL AGENCY D:a C'si OUM)TANK
<br /> SP ,1:FOR
<br /> 3. Please i r,,`�or print clearly all rcques1c< i tfortn lion,
<br /> A. Use shard point writing i ;;trunicnt.yuwt are making;3 cotncs.
<br /> TOP OF MRM.-"MARK ONLY ONE r1T.M'
<br /> 1. lark an (Y)in the box next to the:itern that best describes the reason the form is being completed,
<br /> 2, lnciicaCe t??e C)E azar 1 acility scan e wh ter. the tank is instaalled.
<br /> 1. 'I°ANK I)IW.R111t°I6 -C C?mm,.t<:m!ALL tI1: ,a;..it?UNKNOWN-SC;,t 1xXilrY
<br /> A. Indicate owners, trick ID If there is a tank number that is used by the omen to identify tare tank(ex.A1:3707£19).
<br /> 13. Indicate the name of the company thew, rrcmifactuared the tank(ex.AC,MT"s'SANK MFG,).
<br /> C;. Indicate the year the tank was installod (ex, 1987),
<br /> D. Indicate the tang, capacity in gallons (ex,2+,000 or 1#)#K)ctc.),
<br /> I.I. TANK C ONJIINNS
<br /> A. 1 if qO )R V, IItC T 1 C 1`I„check, box 1 and Complete items B C,
<br /> 2. If no: ,,.,C)"TC1T2 V131JIt.hL,F LiI,1. check the appropriate box in section A and complete items 13 D.
<br /> B. Check the appropriate box.
<br /> C, Check the type ofMOTOR VEHICLE.E.IIUF,,S,(if box £ is checked in A).
<br /> I). Prim the;.rhencical name of the hazardous substance stored in the tank and the C,.A.S.#. (Chemical Abstract Service
<br /> number`,. �.box't is NOTchecked in A.
<br /> HI, TANK,C ONST UC7110N-MARK f NU,TITM ONLY Lts1:BOX A,139 C;&CI
<br /> E. Check only one item in"I'Yt'Ia,C'1I 1SYSI' NIl TANK IbtATF.RIAL,1MF'I RI0R LINING and CORROSION 1'TCClTEC"I10N.
<br /> 2. If C?'l`HI"'R,print in the space provided,
<br /> LV. PIPING lN1ak)Rb1 a'I"1C1£J
<br /> 1. Circle A if aboveground; circle 1,T if underground; and circle both if applicable,
<br /> 2. If UNKNOWN,circle, or if OTHER, print in space provided.
<br /> 3. Indicate the;LEAK I)1 1`I1(.Tl N system(s) used to comply with the monitoring)requirement for the piping.
<br /> 1, Indicate the C.,IaAK C)Is` EC"TION system(s)tared to comply with the monitoring requirements for the tank.
<br /> L 1NIk)RMN110N ONTANK PERMAN111MILY 0,OSED IN 111, (li
<br /> 1. Lk4'I"IMNFE I) L7ATF,IA I' C sFID- ON T[,/Y AR (January, 1988 or 01/88),
<br /> 2. I;S 1`NNIA ED QEJAN11'1"x''a:sf IEA:tAttl)C.)U S;SUBSTANC E remaining; in the tank(in Gallons),
<br /> , Wr1"a TANK IalI.1.E,D W1111 INI'K]'l AITIRIAL?Check `k'es'or'NO'.
<br /> APP1 N,r MUSM SIGN AND I)NIE 31111 )11 4 t1.S IND ` `I"L 1).
<br /> INSU'RUC7110N FOR17111 LOCAL AGENCIES
<br /> The state undcraround storave 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 raunchier. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the Sraate Board (91ti)r3aa-2,121, 'I'Ite facility number metal be the same as shore in form"A". The
<br /> tank number may be.assigned by the Ical 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 1,kmk.
<br /> PT"IS"1'111:1C£'-SF ONSIBILnT CII,°["m LOCAL (Tl,. (�Y 1' IA'1'INSPI"'%`11JE F C7111'IT TO I?I2li"Y'111E
<br /> ACCURACY OF 71'II o I )Td '110143 371111 I Cat L, GEN(,' IS I31N ' SIBIE I S 1"I Ix COMP1,1311ION OF T'Il i
<br /> "LOCAL ACHiNCY USE ONLY'INFORMN11ON BOX AND Ik) ..II)ICWARDING ONE]FO 'A" D ASSOCIKITID
<br /> FORM"13"(s)''()11II FOLLOWING ADDRESS.
<br /> 91WIT W I E— URCU CC) I° d)I,BOARD
<br /> CITE)S.W_L:;.E:a-:I'.S,
<br /> P.O.BOX 527
<br /> PARAMOUM17,CA%flT3
<br />
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