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IN9rRU`C711ONS MR COMPLIqlNG,FORM 1B* <br /> GENERAL INSIRUC11ONS- <br /> 1. One FORM "B"shall be completed for each tank for all NEW PFR 1>S,PFRMrr CHANGILS, REMOVALS and/or any <br /> other T" INFORIANFION CHANG11 <br /> 1 This form should be completed by either the PERMIT APPUCAMor the I)OCAL AGENCY UNDERGROUNDTANK <br /> INSPECI'OF- <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'MP OF FORM:'MARK ONLY ONE MW' <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 1 Indicate the,DBA or Facility name where the tank is installed, <br /> 1. TANK DIN MP'ITON- MP11-nm All,rmms-w uNKNowN-so spauy <br /> A. Indicate owners tank ID #- 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.ACMEIANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,OW or 10,000 etc,), <br /> 11. TANK COWENIS <br /> A. 1, If M01POR Vf`.111CLE FUTEL, check box I and complete items B & C. <br /> 1 If not MOTOR VEIlICLF' FULL,check the appropriate box in section A and complete items B&D. <br /> 13. Check the appropriate box, <br /> C. Check the type of,,vto'rOR VE1.11CLE FUEL(if box I is checked in A). <br /> D, Print the chemical name of the hazardous substance stored in the tank and the CA.S,#, (Chemical Abstract Service <br /> number), if box 1.is NOT checked in A. <br /> III. TANK CON'STRU`(TITON-mARK ow mw ONLY IN BOX A,13,C&D <br /> 1, Check only one item in'TYPE OF SYSTEM,TANK MAF[3RIAL, INFERIOR LINING and CORROSION PROTECI'TON. <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING INR ORMNI70N <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTHE'R,print in space provided, <br /> 3. Indicate the LEAK DF.TEMION system(s) used to comply with the monitoring requirwnent for the piping. <br /> V. TANK LF AK 13111W ON <br /> I. Indicate the LEAK DErITC`pJ0N system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INPORMA17ON ON°I' PERMANEN"11M CLOSFD IN PIACE <br /> L 139111MA'110 DATE LAST USED-MOINMI/YEAR(January,1988 or01/88). <br /> 2. ESTIMATED QUANFITY of 1IA7AIZD0US SUB51ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wrni INERT'MATE Check'Yes'or'NO'. <br /> APPIICANI'MU917 SIGN AND D)VFF'IIIE IX)RM AS IM)ICATHI), <br /> INSFRIUCITON 17OR'IIIE LOCAL AGENCTE-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. 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 alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> rr IS 31?RI_zSPONS][BI[XI'Y OF171E WCAL AGI.WCY 1TIA`]7INSPFA,-I'S 17111 FA(31,171T TO FY'11113 <br /> ACCURACY 0171111i INFORMN]ION. 171E WCAL AGFNCY IS RESPONSIBI11 FORTHT;(,OMP1HFIf)N OW1,71E <br /> 'LOCAL AGENCY USE ONLY'INFORIVINHON BOX ANT)FOR FORWARDING ONP 1109M W AND A,SO <br /> FORM W(s)TO 311E 17011DWING ADDRESS. <br /> STWFE OF CAL117ORNIA <br /> S`FATE WA`1TR RE-SOURCIN N" OL 13OARD <br /> C/o&W.Tu'-ps. <br /> D)VrA PROCSSING CTWITIR <br /> PD. BOX 527 <br /> PARAMOUTT,CA 99M <br />