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INN . U(71 0NS FC)R COMPLETING I -Ir
<br /> 1. One FORM"I3"shall be completed for each tank for all NFW PERMITS,PAR S'I'C;F , GRS, REMOVAIS and/or any
<br /> other TANK INq-tORMAXION CHANGE,
<br /> This form should be completed by either the PERMrr APPLIC'.ANI"or the LOCAL AGE UNDERGROUND TAN
<br /> ISF' I'C)R L
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> OP OF TIC) 'MARK ONLY Opli.3 nim
<br /> 1. ` Mark an (X)in the box next to the item that best describes the reason the fonts is being completed.
<br /> 2. Indicate the DBA ear Facility name where the tank is installed.
<br /> I. TANK I) 'RIF1'ION-C O PI,IT E,ALL TIV S IF UNKNOWN-,So fSPI? 111 Y
<br /> A._.. Indicate owners, tank 11)#s If there is a tank number that is used by the owner to identify the tank(ex.AB770789).
<br /> II. Indicate the name of the company that manufactured the tank(ex,AC E TANK MFG,).
<br /> C. Indicate the year the tank was installed(ex. 1ii£3j`).
<br /> I). Indicate the tank capacity in gallons(ex.25,040 or 1.0,000 etc.),
<br /> H. TANK C",C)NPIT N`17,,S
<br /> A. 1. If MOTOR VFIIiC:,I,a l`I I?I.,check box 3 and complete items B & C.
<br /> 2.If not MOTOR V111IICLE FFUFL,cheek the appropriate box in sections A,and complete items B& D.
<br /> B. Chock the appropriate box.
<br /> C, Check the I): Print the chenriral name of �of the hazardous ario s sub (if box 2 e cin thed in k)_
<br /> type,
<br /> substance storedirathe tank and the C.A.a, . (Chemical Abstract Service
<br /> number),if box I is NOT checked in A.
<br /> 111 .TANK C O RUC°110N-MARK ONE r1liM ONLY IN 13OA,13,C;&1)
<br /> 1.. Check only one item inTYPE Of`S-YSTFM,TANK MATERIAL, Iiti IU IOR LINING and CORROSION I'IIOTE(:TION.
<br /> 2.' 1f OTIIEII,print in the space provided.
<br /> IV. PIPING 1NIX)RMJV11ON
<br /> 1. Circle A if above ground; circle U if undergrcund;and circle:boils if applicable.
<br /> 2. If UNKNOWN circle, 0r if 0111I R,print in space,pnwvided.
<br /> 3. Indicate the LE-AK i)a FEC-1ION system(s)used to comply with the monitoring requirement for the pipieag.
<br /> V. TANK LEAK DPI14CIlON
<br /> 1. Indicate the Ll-`sAIC I)Z;TE(.'IION system(s) used to comply with the monitoring requirements for the tank.
<br /> INFORMAnOld ONTANK PIWMANEMILY CLOSED IN PLACE
<br /> 1. F.S"IIMA'I L) A f,' IAST USED-moprrill/YEAR(January, I9 or 01/88).
<br /> 2. ESTI /0 ) LA:` `L`Y of I LAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS=I`ANK FILLED WfIII INE RTMATE,RIA L? ("back 'Yes' €r�NO%
<br /> APP11CANr MUSFSIGN A i) NILl I1W FORM AfS'I IC:A`17-`1 :
<br /> INS17RUC:I'ION FORTHE I.t)CAL,AGENCIF7
<br /> The state underground storage bank identification number is composed of the two digit county numbcr,-the three,digit jurisdiction
<br /> number,the six digit facility number and the six di=git tank number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board(91)739-2421. `I`he facility number must be the same as shown in Corns "A". The
<br /> tank number may be as-signed by the local agency, however,this number trust 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 /> FI' S THE IZENPON II3UX17 'OF THE LOCAL Af a ?('Y INI NSPI7,C7I°li"Ilii?FAC 11,11,M110 VERIFY 1111f
<br /> ACC 1J CY C)IF TI II?INFORMATION. '171E I,C)C;AL AC ENC-Y IS RESPONSIBLE i R 17111 CC) P11HIC) OFz"I11F
<br /> , .AGENCY IJS14 ONLY'INFORMA']VION 13OX AND FOR FORWARDING ONE"FOR 'A"AND ASS 'I'I I)
<br /> IFS 'B'(s)TO'I`IE MILOWING ADDRESS.
<br /> FNI z
<br /> OF CALIFORNIA
<br /> JC)S, Rs.
<br /> I)A'rA PROCILS&ING UIWFER
<br /> P.O.IX) 527
<br /> PARAMOUNr,CA WM
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