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INa.. iJMONS FOR COMPIMING I'(*'lr <br /> M :L N r 2iJ i ON-S. <br /> L One FORM"I3"shall be completed far each tankfcap all NFW N.. PIIR PF-,RMI`I`CII NCII�S, RF.MOVAIS and/or any <br /> other TANK INWORMAMON CIANGF <br /> 2. This form should be completed by either the PERM 17 ,PP11CAmr or the LOCAL AGENCYUNDERGRO TAN <br /> INSPECMIL <br /> 1 Please tyke or print clearly all requested information. <br /> =I. Use a hard point writing instrument,you;are making a copies. <br /> TOP OF M)RM.-"MARK ONLY ONE IMM' <br /> L Mark an (X) in the box next to i eF 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. TANK 17i? RIFIION-CY)M1ri i M,ALL r.1'IIMS-IF UNKNOWN-SO;a"€IN11 <br /> A. Indicate owners tank 11) -If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMI''IANim MFG.), <br /> C. Indicate the year the; tank was installed(ex. 1e97). <br /> 1). Indicate the tank capacity in gallons(ex,25,000 or 10,000 etc.). <br /> Ii. TANK C ONIT. '4 <br /> A. 1, If MOTOR VFIIIC'Lii F )I°sL,,check box 1 and complete items B& C. <br /> .If not MO'.['OR VI IIIC°LE t IT"L, check the appro=priate box in section A;and complete items B & D. <br /> B3 Check the appropriate box. <br /> C. Check the type of M()'I`OR V17,111Ct,L fIIEL(if box 1 is checked in A). <br /> I). Pont 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 NCl":i checked in A. <br /> Tina "I'ANKON'T.MUMON._MARK ONE MM ONLY IN WX A,ti,C& ) <br /> 1.. C=heck only one iters: in' YPE C?I'SYS7"EK TANK MISTp IAL, INTERIOR LINING and CORROSION I'12OTEC CION. <br /> `?. If OTHEi(,print in the space provided. <br /> IV. PIPING INFORMAMN <br /> 1. Circle A.if aboveground; circle't3 if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle, or if E3"I IER,print in space provided. <br /> 3. Indicate the LEAK T'}.ET C"`ON system(s)used to comply with the monitor ng requirement for the piping. <br /> V. TANK L t K DFIVC11)N <br /> I. Indicate the LEAR I)L7FI.C;F1ON system(s) used to comply with the monitorima requirements for the tank. <br /> . INFORMA110N C3PI'I`ANK PER r [`IA's CLOSED IN PLACE <br /> 1, F'SHMA'FED r1'EI: LAST GSED-MO IJ/YI (January, 1988 or 01/88). <br /> 2. ESTIM/01 l)'QUANTIT of IIAZA I)O S SUBSIANCE remaining in the tank (in Gallons). <br /> 1 WAS'I'ANIC FILLED FYI°1'II INERT I4U IERIAL?(,heck'Yes'-or NO'. <br /> AI P11 ' r S`I'SIGN AND /VIII("IIF?FORM AS INDMNIM. <br /> INFIRUC11ON FORM ILI U)C'.AL AGIJ.NC;I S <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.. `1`he facility number must be the carne as shown in form "t1. -a.'he <br /> tank number may be assigned by the local a enc°l; 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 /> i'I'IS 11II RESPO SIBI1 I"I"I€F 11M L(XALA(qGE�pNgC; 7 fIA'I'INSP , 'S"I I?Ia.I <.II:TI' `"'t3 VI IIF nIE <br /> ACC IJ C`Y ()iz 17113 Nit() LOCAL 10 <br /> 7N."'171B A AGENC" IS RESPONSIBLE MR 17111 COMPLL C)N 0171111T, <br /> 'LOCAL AGENUS ONLY'INFORMA110N BOX ANIS FOR FORWARDING ONE i 'A'AND ASSOCINJIM <br /> FORM'Ir(s)10 ME FQH,0WING ADDRESS. <br /> iMilr,OF CAIMURNIA <br /> Sr -t'EWA`I'iEii RFMURCM COMPROL BOARD <br /> C/o 5. . . 1".S. <br /> DXrA PROC,;''IN , . IM <br /> P.O.BOX 527 <br /> P MOUNT,C' 90723 <br /> I <br /> I <br />