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INSTRUCHON'S IX)R COMPLHIING 14B"
<br /> GENERAL IN,51-RUCDONS:
<br /> 1, One FORM IV shall be completed for each tank;for all NFW PERMY11i,PERMITCHANGES, RFMOVALS and/or any;
<br /> other TAN I'10N(711ANGE.
<br /> 2. °Phis forte should be completed by either the PERmn'APPLICANT or the LOCAL ACi13N UNDERGROUND TANK
<br /> INSP,, 1 R
<br /> 3. Please type of print clearly all requested information,
<br /> 4. Use a hard point writing instrument,you are making 3 copies.
<br /> `MP FORM.'MARK ONLY ONE tIFR 1"
<br /> L ?Stark an (X) in the box next to the itean that fust describes the reason tate form is being completed.
<br /> 2. Indicate the DBA or Facility name where the tank is installed,
<br /> I, TANK.DESC>RI11'1ON-C`OMP11IITI ALL r1liM4-IF UNKNOWN-S0 ISPIWIF
<br /> A. Indicate owners WI)# -If there is a hank number that is used,by the owner to identify tha.tank(ex.AI370789).
<br /> 13. Indicate: the name of the company that manufactured the tank (ex.AC Ea IANK MF'G.).
<br /> C. Indicate the year the tank was installed(ex, 1987).
<br /> I). Indicate; the tank capacity in gallons(ex.25,00(0 or 10,E etc.).
<br /> H. TANK C ON1'1 mN'I S
<br /> A. 1.. If MOTOR VEHICLE.FUfd.,cheek box 2 and complete items II& C,
<br /> 2,If not M.OTOR V1 I11C:LE FUEL,check the appropriate box in section A anis complete items B & D.
<br /> B. Check the appropriate box.
<br /> C. Cheek the type of MOTOR VEHICLE FUEL(if box 1 is checked in A).'
<br /> IJ° Print the chemical,name of the hazardous substance stored in the tank and the f,:.A.S, .(C<henaical Abstract Service
<br /> number),if box I is NOT checked in A,
<br /> H1. TANK ON :(TnON-MARK ON14 DIM ONLY IN BOX A,13,C°&E1
<br /> 1. Check only one item in TYPE OF SYSTE ,`,`oN C MATERIAL, IISF RIOR LINING and CORROSION PROTECTION.
<br /> TION.
<br /> 2, If C)THEi,11,print in the space provided.
<br /> PIPING,Cl I RM)VO sty[
<br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable.
<br /> 2. If UNKNOWN,circle, or of 0`171E?R,print in space provided.
<br /> 3. Indicate the LEAK IA- LC-FI N system(s)used to comply=with the monitoring requirement for the,piping.
<br /> V. TANK LEAK DITI'FCOON
<br /> L Indicate the I,1::AK I3F I,C'I10N system(s) used to comply with themonitoring requirements for the hank.
<br /> INF`£) a 1-ION ONTANK PI3RMANE '1'x-C,'I ST,13 IN PLACE
<br /> L PS11MATED DA11,L.AsT USE[)_Ivff Nmi/YF,AR(January, 1988 or 01/88).
<br /> 2. ESTI-MATED Q AIN-1.1 y of I-ItA7AI)OUS SUB51ANCE remaining in the tank (in Gallons).
<br /> 3. WAST./\NK FILLED WITII` TIINERT F'7iRlJNL'C heck'Yes'ar'NO'.
<br /> APPLICANT S~"SIGN AND DATETHE HE 19 AS INDIONFED,
<br /> 1N U(T1 ON L I '`I33:wC".AI.,mmIINaus
<br /> The state underground storage 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 number. The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the state Board (916)739-2421. The facility number must be the same as shown in fear A'. The
<br /> tank number may be assigned by the local aggency; lacnoever, 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 blank.
<br /> '1'IS IP? 0;P0JNS HXp OFTHE 1 " L AGI?NEY T1IX1`INSPEr,1',S'IIIE FACUMTO VERIFY 17II?
<br /> ACCURACTY C)1 TBPA INFO ATICtN. '171 W(:Al,AGENCY IS RESPONSIB114'.1 Et'E711;CFOMPI,EUION OF"[Bit;
<br /> C Al AGENCY USF t ONLY"INFORMATION AND It£3R IX)R FSIt £a,C3NI:A-�C)I2 t®gymAND Aa " C7 i'I-0
<br /> R) -Ir(s)-1011111 1701.1-OWING,AI)D S.
<br /> ,5E'A'111 CFI CALHURNIA
<br /> fi A" `1'EiR - .€JRC; SCON17ROLBOARD
<br /> C/o smaavi
<br /> DNIA,PROC &S1NCa CENIER
<br /> P.C.13OX 521
<br /> ISA OUNI-,CA 90723,
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