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tN1;I'RU(7IONS FOR COMPLUITNG FORM'B" <br /> GENERA1.1N,1;I'RUCI1ON.S- <br /> L One FORM "B"shall be completed for each tank for all NEW PERMITS,PERmn,(aIANGF-s, PJNOVAI-S and/or any <br /> other TANK INFORMATION CMANGF- <br /> 2, This form should be completed by either the PEWiffl'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR- <br /> 3. Please type or.print clearly all requested information, <br /> 4.'- Use a bard'Iyoint writingtrutilent,"You are making 3 topic&\ <br /> aw OF FORM:-MARK omx ONE ITEM- <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed, <br /> 2. Indicate the D13A or Ficility name where the tank is installed. <br /> L TANK DF-SCRIlYI70N-COMPIZI'L4 ALL rIVIW3-IF UNKNOWN-SO SPEC117Y <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,(Fx.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex. 25,000 or 10,(00 etc.). <br /> 11. TANK CON11WIN <br /> A. 1. If MOTOR VEHICLE I:UEI,,check box 1 and complete items B&C. <br /> 1 If. not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B&D. <br /> B. Check the appropriate box. <br /> C. Check the type of moTOR VEHICLE FUEL(if box 1 is checked in A). <br /> 1.), Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical Abstract Strvice <br /> number), if box I is NOT checked in A. <br /> 111. TANK CONS.MU(7110N-btARK.crmi mm omx IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTa."RIOR LINING and CORROSION PR0TFCI'ION. <br /> 2. If O'HIER, print in the space provided. <br /> IV. PIPING TNFORM/VI1ON <br /> 1. Circle A if above ground; circle U if underground,,and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if 0111FIZ,print in space provided. <br /> 3. Indicate the LEAK DIvITC TFC7 sy-,tem(s)used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DUIWIION <br /> 1. Indicate the LEAK D17f I ECHONsystem(s) used to comply with the monitoring requirements for the tki- <br /> VI. INEORS&N17ON ON TAMC PERMANFMI.Y CI.OSED IN PIACE <br /> L ESTIMATED DA'I I E LAST USED-MONTIJJYFAR(January, 1988 or 01/88). <br /> 2. r!sTimATEm QuA.\rj-riy of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), <br /> 3. WAS TANK FILLEI) WITI I INERT MATE RIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA113111I3 FONCA717ED. <br /> INS;1`RUC7nON PORTHE LOCAL AGENCIES <br /> The state underground storage tank identification number N 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 am 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 EP)ard to assign the tank number,please leave it blank. <br /> IT ISTHE RES1'ONSIBIT11Y OF THE LOCAL AGENCY"THAT wsptxas iulli mcmmy,ro vERnly TItE <br /> A(.X'URAC'YOI?'1111:1�", R,MA'IION, '111H,LOCALAGENCY IS RESPONSIBIJ!FOR 111E COMPLETION OF*RIE <br /> 'LOCAL AGF.N(Y US ONLY" lNFORMA.11ON IX)X AND FOR FORWARDING ONE FORM'A7 AND AW)CIXIMD <br /> FORM-13-(s)TO-111E FOLD-01WING ADDRI-,S& <br /> MWIT OF CALWORNIA <br /> S-F/VIT!W)VII,R RESOURCKS CONTROL BOARD <br /> C/o&W.RF-P.s. <br /> DATA PROCIMING C7,N1711M <br /> P.O.BOX 527 - <br /> PA MOUNT, <br /> PARAMOUNr,CA 90M <br />