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�11 7-1 <br /> INSTRUCTIONS 17OR COMPLETING FORM ir <br /> GENERAL INSTRUCTIONS. <br /> L One FORM "B"shall be completed for each tank for all NEW PERNITIN,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGt! <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECI[IOR. <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'FORM: *MARK ONLY ONE r11W <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 DBA or Facility name where the tank is installed. <br /> 1. TANK DESCRIVI'ION-COMP11ME AM 1171IMS-IF UNKNOWN-so SPE(Mry <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.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 10,000 etc.). <br /> 11. TANK COMIT.W.—IN, <br /> A. 1.If MOTOR VEHICLE FUEL,check box I and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items H&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE 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.A.S.#. (Chemical Abstract Service <br /> number), if box 1.is NOT checked in A. <br /> U1. TANK cA)NsrRU(,'nON-MARK ONE.niN ONLY IN BOX A,B,C&D <br /> L Check only one item in TYPE OF SY917EM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if O'I1IEF,' print in space provided. <br /> 3. Indicate the LEAK DI:I'EC1'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI.Tnx*nON <br /> 1. Indicate the LEAK DI'411EC11ON system(s)used to comply with the monitoring requirements for the tank, <br /> VL IN14ORMAIION ON TANK PFRMANI:NI1,Y(TOSED IN PI.ACTi <br /> 1. EST'IMAT'ED DATE I.ASI`USED-MONI'II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANHTY of HAZARDOUS SUBSTANCE rema;ning in the tank(in Gallons). <br /> 4 <br /> 3. WAS TANK Wlr.['Il INERT MA'I'ERIAL? Check 'Yes'or'NO'. <br /> APPI1CAN1 MUST SIGN AND DATE 311B FORPAS INDICATED. <br /> (.—� <br /> iNirRU(31ON FOR 111E WCAL AGENCIES <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 /> TI'IS TI IE RESPONSIBILITY OF 111H LOCAL AG17NCY 11INIANSPECIN11112 FACHXff TO VERIFY IIIE <br /> ACCURACY OFTIIE INFORMKIION. 371131 LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLU11ON OF nIE <br /> 71A)CAL AGI.NCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM*A*AND ASSOCIN11a) <br /> FORM'Ir(s)TO-11111 POI-LOWING ADDRESS. <br /> STATE OF CAI HIORNIA <br /> SI'MIE WATER RESOURCES CONTROL BOARD <br /> C/o sxEnrx <br /> DATA PROCESSING CTNIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />