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INSTRUMONS M.R COMPLFFING M I <br /> GENS I. ISI rR C!Tl NS: <br /> 1. One FORM"I3'shall be completedfor each tank for all NEW P ?R �,Ps1dT1 CHANGES, REMOVA1,S and/or any <br /> otherTANK IpIFORMKIION 01AN L? <br /> 1 This form should be completed by either the PERmrr APPLHANr or the LOCAL AGENCY UNDERGROUNI)TANK <br /> IN:SP .I'S)T£ <br /> 1 please type or print clearly all requested information. <br /> 4. Use a lard point writing instrument,you are making 3 copies. <br /> "F°t)1"OF VORM.%MARK ONLY ONE ME <br /> 1. Mark ars O in the box next to the item that best describes the reason the form is being completed: <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TAN 171-SC.°ItIT"I.I()N- O PIHM,ALL 171TUS-IF UNKNOWN-So SPIXarry <br /> A. Indicate owners, tank 11:3 -,lf there: is a tank number that is used by the:owner to identify the tank(ex.AB70789). <br /> 13. Indicate the name of the company that manufactured the tank (ex.AC i?'IIA K Mfr=C3.)." <br /> C. Indicate the year the tank was installe=d (ex. 1€9£37). <br /> 13. Indicate;the tank capacity in gallons(ex.25,0or:10,000 etc.). <br /> 11. TANK MMMMIN <br /> Al 1.If MOTOR VI°I IICLE FUEL,check box I and complete items I:3& C. <br /> 2.If not MOTOR V1.11ICLE FUJI..,check the appropriate box in section A and complete items k3.& D. <br /> Ef. Check the appropriate box. <br /> C". Check the type of MOTOR VEHIt I l FUEL(if box I is checked in A). <br /> D, Print The chemical name of the hazardous substance stored in the tank and the C;.t1.S. . (Chenticat abstract Service" <br /> number),if box 1 is NOT checked in A. <br /> III. TANK C()N:� I£ I"it) -mARK olsir,rnm ONLY IN BOX A, I,C:&D <br /> 1. Check only one item in"["YPE Of,Sy5"l'I'm,'1ANK MATERIAL, INTERIOR LININ)anis CORROSION PROT1 C;i'ON. <br /> 2. if OTHER,print in the space provided. <br /> IV. PIPING INt ORM)ON <br /> 1. Circle A if above ground; circle _T if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if O'llIE R,print in space pmwidecl. <br /> 3. Indicate the LU,,K DE-I.-I:MION systezn(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IXAK DITITiC7110N <br /> �1, Indicate the LIsA1C 171 1:Z,<'I'.t34 systean(s) used to comply with the monitoring recluis: ments for the tank. <br /> VI. INFORMAIION ONTANK PERMANI MMY C;I SItD IN PI C:? <br /> L F-5111r MED I3ATI.i LAST USED-lvtfJN'3"H/YfAR(January, 19E18 or 01/88). <br /> 2. ESTIMATE13 O AN'`3:'ITY€f HAZARDOUS SUB51ANCE remaining its the tank(in Gallons): <br /> 3. WAS'1 ANK FILL 1)WITI I FEWER`MATERIAL? Check'Yes'or'.NO,. <br /> APPII(AW MOST SIGN AND D °M 11-i?FO £ ILID. <br /> IN.. U(71'10N FORTHE IA)CAI,AGIMMIDS <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 member. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board(916)739-3421, The facility number must be the same as shown in forth"A'. The <br /> tank number may be assigned by the local 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 blank. <br /> r'IS THE RESPONSIB11IFY OF ME 1,£ C Y 'I INSPI I `11113 FACILMY TO Y'r1313 <br /> AC £:Y OF IME I FO 11C)N. '11 1 AGENCY IS RESPONSIBLP FOR 17111 C OMM , ON OFTHE <br /> 'LOCAL AGENCY USF ONLVINK)RMAMON BOX AND FOR IrC RIVARDING ow I -A-AND Asw)aKrm <br /> SL" MOF CALIFORNIA <br /> °irk l )VIfI .R URCF °I OL BOARD- <br /> DXI'A PROCESSING FER <br /> P.O.11�$O$X5pp2�7PARAy <br /> /y,gg+ �-e♦ <br />