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IN.S, €TC11ONS MR C:C) "11717ING I *T3"
<br /> GENERAL L INi"ItI7 I'ONS
<br /> L One FOI24i"II"shall be completed for each tank for all NEW PERNITIN, PF1Etmrr CHANGES, REMOVATIS and/or any
<br /> otharTANK INFORMN110N C HANG z
<br /> 2,
<br /> This force Should be completed by either the PFRmrr PL.IC ANI'or the IXC i.,AGFINCY UNDERGROUNDTANK
<br /> TISI' _I'II2
<br /> 3, Tease type or print clearly all requested information.
<br /> 4: Use a hand point.writing instrument,you are making 3 copies.
<br /> CDI�OF IX)RM:*MARK ONLY ONE rrEm,
<br /> 'L Mark an (X)in the box,next to the: item that gest describes the reason thef`cn is being completed.
<br /> 2. Indicate the.DBA or Facility name where the tank is installed.
<br /> I. TANK 37F—S :RII-HON-COMPI,,s"f:ALI,I'I"F7I S-- I'UNKNOWN-S£)S`I'a
<br /> A, Indicate owners tank IIS#-If there is a tank number that is used by the crwner to identify the tank(ex.AB70789).
<br /> F3, Indicate the name of the company that manufactured the tank(ex,AC'MI.7,TAN MFG,).
<br /> C. Indicate the year the tares:was installed(ex. 1987).
<br /> D. Indicate the tank capacity in gallons(ex.25,€,00 or 10,000 etc.).
<br /> 11. TANK C O ? I
<br /> A 1. If MC31C3R Vl IIICI,E I1JI:L,check box 1 and complete iteans I3 c&C.
<br /> ,2.1.f not MOTOR Vf Al C LE FURL,cheek the appropriate box in section A and complete items B <& D.
<br /> is Check the appropriate box,
<br /> C. Check the type of STCfl()R VEHIt I I:FUEL(if box"I is checked in A),
<br /> Print the chemical name of the hazardous substance stored in the tank and the C;.A:S. .(Chemical Abstract Service
<br /> number),if box I is ;Ncyr checked in A.
<br /> III. TANK CC) ISI"R IC J,`IO ,.MARK ONE I"I°TI ONLY IN 13OX A,11,C&iy
<br /> 1.. Check only one item in TYPE£3I SysrE ,` ANK MATERIAL, INIURIOR LINLNG and CORROSION PROTF...C'1710N.
<br /> 1 If t7TIMT,print in the space provided,'
<br /> TV® 'IIS CI INFORMNFION
<br /> L Circle A if above ground,circle I if underground; and circle troth if applicable.
<br /> 2, If UNKNOWN,circle,, or of O'l'I IItIZ,print in space provided.
<br /> 3. Indicate,the I,1�,',.3R i3.f k C 1"IC7 R systczn s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK IIUt'a,C; O
<br /> L Indicate the LTAK I)ETEC'I'IC:N systetn(s) used to comply with the monitoring requirements for the tank.
<br /> I i'C1 °T'If N O `E MC ER I?I* IX CLOSED I P C I:�
<br /> J. ESTIMATED I7A"t"E IAST US1,"D-MONr1`ll/YEA 2 (January, 188 or 01/88).
<br /> 2. I SFMIzVIT,D C,)L, N 1' Y of HAZARDOUS,vsLlBSI't1NrCT,, remaining in the tank(in Gallons).
<br /> 3. WASTANK FILLED WITH INEIC"'MATERl.AL? Check'Yes' or'y,10%
<br /> APPII(AW MUF SIGN Am Iwm°nilft Isom As I. IC.mm),
<br /> INS LIC'I°TON PDR11IR WCAL!GEE C'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 sire digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtaincd by calling the State Board(91.0739-2421. The facility number must tic the same as shown in form "A". The
<br /> tank number may be assigned by the local agency, however, this number crust 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 /> rI`IS TIHI RESPONSIBUX17YOF TETE LOCAL rACXXIT'll)VERIFT1111I
<br /> ACCURAComOF THE INFORMATION. ILL?LOCAL AGFN `Y IS RESPO SIi3T,l,x E'CIR CHIP?COMP 1MON CII' `III.
<br /> *1k , , OIlNCY US13 ONLY'1N1hORMAnON BOX ND FOR FORWARDING ONE:FORM'A*AND St`OCINI D
<br /> MRM"E3°(s)TCI='I°IIIT I701.1I IN DD
<br /> '517M 11 OF CAMFORNIA
<br /> lWM,WIMIR RESOURCESCOMMOL OL SRI?
<br /> C/o .a .ILTr
<br /> DMA PRO( _ °I G CIWIMR'
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