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ENSI A1C 11ONS FOR CoMPLE,10ORM <br /> GENFRAL E IXUC"TIONS: <br /> 1, One FORM"£3"shall be completed for each tank for all NEW PER . 1'S,PERMIT CHANGES, RI: (YVAI and/or any <br /> Cather TANK INMRMAIION C 1 I-. <br /> 2. `Phis form should be completed by either the PERMIT APPLICANT or the IA)CAI,AGENCY UN11:7Itt3RO 13 TA K <br /> INSPEC170R. <br /> 3, Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF IZORM:'MARK ONLY ONE 11TEM, <br /> L _ Mark an (X)in the box next to the item that best describes the reason the form is tieing completed, <br /> 1 Indicate the DBA or facility name where the tank is installed. <br /> I. TANK ISIS I PION-COMPIHIM ALL rII : IF UNKNOWN-SO SPI CIIS <br /> A, Indicate owners tank ID#W If there is a tank number that is used by the owner to identify the tank(ex.AII70789), <br /> B. Indicate the name of the company that manufactured the tank(ex..ACME TANK MFG.). <br /> C� Indicate the year the tank was installed (ex. 1987). <br /> 11. Indicate the tank capacity in gallons(est.7-5,000 or 10,000 etc,). <br /> IL TANK CONE'FAVID <br /> A. 1.If MOTOR VEHICLE FUE'L,check box 1 and complete items I1 & C. <br /> 2.If not MO1'OR VEHICLE FUEL,check the appropriate box in section A and complete items Ii& D. <br /> B. Check the appropriate box. <br /> Cr. Check the type of MOTOR VEHICLE FUEL(if box.I is checked in A). <br /> I3. Print the chemical name of the hazardous substance stored in the tank and the C°.A.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSTRI.J01ON-MARK ONE ITIM.ONLY IN l3OXA,II„C&I) <br /> 1. Check only one item in TYPE OF SYSI M,TANK MATERIAL, IN"T RIOR LINING and CORROSION PROTECTION, <br /> . If C7'.I'TIER,print in the;space provided. <br /> I . PIPING IN11ORMN110N <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECTIION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I.EI.A DE`1 a CTS <br /> 1. `Indicate the LFAK D C`110 system(s)used to comply with the monitoring requirements for the tank. <br /> INIZORMKIION ON TANK PERMANLWILY C . SED IN PIACI? <br /> 1. ESTIMATED DNI'E I.A USED-MON'I°II Ii(.1mmary, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBS`T'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK"11, LLED wriii INERTMATERIAL?Check`"Yes'or'NO'. <br /> APPLICANT US717 SIGN AND DAIMI THEi FORM AS INDICATED. <br /> IN.5rRUCTION FORTHE LOCAL AGENCIEN <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 form "A', The <br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabcL If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT IST11H RINPONSIBILITY OP7111E 1E AGENCY °I`INSPI"S 71111 FACILT17Y TO ICIT 1 <br /> AC ,C1: 1 OF IE I ➢ . T'I m I .,OC` ACII7,N IS S NSIITI,I;FOR 11I MPI.aEIT1ON OF111H <br /> mIA)CAL AGENCY USE ONLY'INFORMN11ON BOX AND I2 FORWARDING ONE FORM"Aw AND A.S%O `n7 <br /> FORM-1r(s)1`0 11113 FOIJOWINGADDRT-SSA <br /> 'T A3711 OF CALIFORNIA <br /> smm wATvR tam)URCM COMPROL BOARD <br /> C,/O <br /> D rA PROCESSING CI I°iI <br /> P.O.BOX 527 <br /> PARAMOUNI',CA <br />