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1.p <br /> I o)-l'RU(T110NS I70II C:OMPLM G FC) "EI" <br /> GENERAL INSI'RUC:'11ONS. <br /> 1. One FORM"B" shall be completed for each tank for all NFW Pl..,Rmrrs,PERmn,CIIANGFS, REMOVALS and/or any <br /> other'I:ANK INFORMA11ON C IIANGE. <br /> 1 'nis form should be completed by either the-PERM I'APPL1C'.ANT or the LOCAL AGENCY UNDERGROUNDTANK <br /> INSPI.C"MR. <br /> 3. Please€ypc or print clearly all requested information. <br /> 4. Use a hard point writtttg instrument,,yQu,are making 3 copiers. , <br /> IOP OF IX)RM: RIC ONLY ONE MiM" <br /> 1. Mark an (X)in Ch€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 /> L 'PANIC DESCRIVITON-C_"OMPLU]fLI ALL r:IEPAS-III UNKNOWN-R)SPECIFY <br /> A, Indicate owners tank Ill #-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 /> II. "TANK C;ONI1?N"CS <br /> A. 1, If MOTOR V1111013 E1 I L,check box I and complete items B&C. <br /> 2. If not MOTOR VEHICLE MI3L,check the appropriate box in section A and complete items B& D. <br /> 13. Check the appropriate;box. . <br /> C. Check the type of MOTOR VEHICLE FUF"L(if box 1 is checked in A). <br /> E7. Print 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 NOT checked in A. <br /> III. TANK CONS UC CION-NIARK ONI rt w ONLY IN I3OX A,B,C&I3 <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INI'T,"RIOR LINING and CORROSION PROTECTION, <br /> 2. If OTHER, print in the space provided. <br /> IV. PIPING INFORMA710N { <br /> 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 LBAK I)I;I`I"C7I1ON sy-stem(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK 11�AIC I)EE I E I1C7N <br /> 1. Indicate the L17AK DFIF CI`I0N system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA:11ON ON TANK PEIRMANtzMIX C"I.OSE D IN PI.AC:E <br /> 1. I:snMATE D I)ATF I,AST USED-'LIONTI-IfYFAR(January, 1988 or 01./88). <br /> 2, E-SITMAT'ED QUAv''1TI'Y of IEAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK F'II_LEI3 Wn11 INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPIlcAmr MUST SIC1N AND I1JVOT'I'IIE 17OICM AS INDICNII I). <br /> INS112I IC711ON ICOR 111E LOCAL 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 /> Cf IS'ITIE?RE?SPONSIBII.IIY OF ITIE3 LOCAL AGPNC.`Y IIIA"INSPER7117S EllE I7ACILII'Y"1'O VERIFY"1111 <br /> ACCURACY Ofe'E11H IEJI'C1'I2MA71TO . 'I7IIEI LOCAL AGENCY IS RESPONSIBLE?FOR'111E,COMPIXMON OF THE <br /> "LOCAL AGENCY USI?ONLY"IhII ORNINITON ROX AND FOR FORWARDING ONE FORM"A"AND ASSOCIA310 <br /> FOR '11'(s)O THE FOLLOWING ADDRE-SS, <br /> S W113 OF CALIFORNIA <br /> 51'XIV WiVI1?R RE SOURCEN C'CPNFROL BClARD <br /> C/O Sm l?E? <br />