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<br /> IN,`rFR(.)C'110N,S FOR C°C)I PI.I;i°TNCS IT RM 11 _ W�
<br /> Gl'W? L INS1'R1.`C'1T_)NS,
<br /> t. One E"=.:k1f%1l "13,sl',a.11b +;, y
<br /> c a rnts..�E �ifo- i" >� I I „PERMIT C It NGEN, REMO I. any
<br /> on
<br /> This ,ar: hoxit1 be coraple ed by ctr.,,; ,ncERmyr APPIK".10IXF or the L0(.:AL AGINCY UN 3I_I CvI8. UND TAN
<br /> . I"leasc ope or print clearly all r quested ;nfo ruction.
<br /> 4Use a ha< dl,'paint writing instrument,y u trc making 3 copies.
<br /> TOP OF FORM,WARK ONLY ONE:rIE
<br /> 1. Mark ars (X) in the box next to the,teat.that best describes the reason the farm is.wing completed.
<br /> 2. Indicate the D15A or 111citity name whe:�the tarok is installcd.
<br /> L TANK DF ..'RT `1 -C;OMPL rE All, W UNKNOWN-SGI 8#4301",Y ;
<br /> A, Indicate owners tank 11:) # m If there is a tsnk number that is used by the ouner to identify the task(ex.AB70789).
<br /> ►1, indica=.e: =tae nanse of the company that. manufactured the tank(ex.ACMETANK MFG.),
<br /> C;. Indicate the year the tank was installe6 (ex, 1987).
<br /> 13. Indicate the task capacity in gl llons (wr. ?5,000 or 1(A)o etc.).
<br /> II, TANK C'O I'1'.13,N
<br /> A. 1. tl 1tis'P)R V1,I IIC,L,E,I i E°;'J., check box 'l, and complete iters I1& f'.
<br /> 2. If not MOTOR VEHlCLF p`LJF`.L, check the appropriate(sax in section A and complete items II &D.
<br /> II. Check the appropriate box.
<br /> C;. Check the type of MC')'IOR VEHICLE l Irl i C.(if box 1 is checked in A).
<br /> 1). Print !he Ebcnhcal narstc of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service
<br /> numb,":r), ff box IE is N0T wrecked in A,
<br /> M. 1AN 1 CONgrRUCNION-MAID ?)NII IfIEM ONLY IN BOX A,I1,C:&I)
<br /> L Check only one iter,inTYPE OF SYS111`AI.TANK MATP.RIAL,INI'ERIOR LINING and CORROSION I'RoTEC:110N,
<br /> 2. H 0111IFT,print in the spare provided,
<br /> IV. KPINCIINFORMATION
<br /> 1. Circle A if above ground, circle U if underground;and circle berth if applicable,
<br /> 2. If UNKNOWN, circle; or if C)TII i2,print its space provided,
<br /> 3. Indicate the LE A&I)I^,17,C.I ON sysiern(s) used to comply with the monitoring requirement for the piping.
<br /> V. `I°ANK I Ir.A I(NI Ei "*10
<br /> L Indicate the LI-AK t)I,TEC,I10N systenr(s) used to consply nth the monitoring requirements fora the tank.
<br /> I. INK)RMA71TON ONTANK NK P1lR ANEWIT CIDSFID IN PI.AC:I?
<br /> 1, ESTIMATE11) DA'1T°,lA S I`L?SFD-MO I`tUYEA (January, 19€38 or W/88).
<br /> 2. TW11MATF."1)QUAvv111'4 of 11,°41`Ad2i3E:31'�S SL7L1ST/VN,C'I:reme;ping;in the tank (in Gallons),
<br /> 3. WAS'TANK FILLJE17 WITH INEK"I"MA'ITT AL?Check'Yes' or'N(.)'.
<br /> IsPJJCA `I muw:SIGN AND l:k °`I 11111,IN)WA AS, INDT(WI"E?I).
<br /> IN I` EJ(:L G)N FORA111i.IAXW,AGENCIES
<br /> I
<br /> The state underground sternage^tank identification number is composed of the taws 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 oboiracd by calling the State Boars (916)739-2421 The facility number,rust be the same as shown in form".A". The
<br /> tank number may be assigned by the Scx°al agency, however, this number rust be numerical and cannot contain an alphabet. If
<br /> the local agency,prefers the State Board to assign the tank number, please leave it:blartk.
<br /> H IES"111ITT S}'ONSIBUXI" F 1 1II WC:AL GE?N(TY 11IA`I'INS 1.TX7l '111E FACyILn'Y`I1C)VE IFY".111
<br /> ACCURA('Y OF 17111 INITCI 110Nm 'Hill L00%A(;I'tNC*Y IS RESTONSIBLE PO 11111(nmmunoN own
<br /> OLOC.AL AGE USE ONLY'INFORMY010N BO SNI)POR FORWARDING ONIEPORM W D. C W.I`III)
<br /> k)R W(s)"1`C '1'[11?FOLLOWING INN AI)DRIIS,S.
<br /> I:A`I OF CAJIFORNIA
<br /> 1willi, /VIEI3 I3.C' C) I"12.01,BOARD
<br /> C:/13
<br /> DKFA P ROC."I:WSNG C ? I IC
<br /> 0.TX)X 527
<br />
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