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A S�I'RUCI"If)NS 1,T)R C:OMPLINING FO -B- <br /> GENERAL INS I'RUC`I10NS: <br /> 1. One FORM RM"II"shalt be Completed for each tank for all NEW PLUM ,PERM11'I'C"IIANGES, RIiMOVAI S and/or any <br /> 3 other TANK INFORMiVI ON(MANGE. <br /> 2, This form should be completed by either the PERM I'APPLICANT or the LOCAL AGENCY.UNDETRGROUNDTANK <br /> INSi M.71'OR <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a"hard point writing instrument,you are making 3 copies. t <br /> TOP OF FORM: "MARK ONLY ONE TIMM' <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 D13SC;RII"I'ION-COMPLI?'I73 ALL,II73MS-IF UNKNOWN-SO SPECIFY <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.ACME TANK MFG,). <br /> C. Indicate the year the tank was installed (ex. 19(37). <br /> D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). <br /> II. 'PANIC C;ON IT iN'I S <br /> A. 1, If MUI'OR VEHICLE E"UEL, check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE MF1-check the appropriate box in section A and complete items B& D, <br /> I3, Check the appropriate box. <br /> C. Check the type of MOTOR TOR V1,111CLE FUEL(if box 1 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 2 is NOT checked in A. <br /> III. TANK coN UC`IAON-MARK ONI I'I'?M ONLY IN BOX A,B,C."&D <br /> 1, Check only one item in TYPF OF SYSTEM,TANK MATFRIAL, INFERIOR LINING and CORROSION PRO"TECI`ION. <br /> 2. If OTHER,print in the space provided. <br /> 1V. PIPING INFORMt1I'ION <br /> L C=ircle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OTHE P.print in space provided. <br /> 3. Indicate the LEAK DFAT"C'11ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK 117AK DVI'I?C'11ON <br /> L Indicate the LEAK DI`I'FC'I'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTII.Y CLOSED PIAC E <br /> 1. ES"I'IMATED DATE, I.AS'I`USI,'D- r ONTIIfYF•\R(January, 1988 or 01/88). <br /> 2, Fi'4I'IMATk','D QUAD"I"II'Y of f A7AR OUS SUBS'I'ANC 13 remaining in the tank(in Gallons). <br /> 3. WAS'IANK FRLED WI'I'I1 INERT MA°I"ERIAL? Cheek 'Yes'or'NO'. <br /> APP( SIGN AND OA'I1!`I1IE W)RM AS I IC;A'IT:11 <br /> INSTRI6C`I"ON FOR'I HE LOCAL AGENCIES <br /> '11'hc 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 kw.al aageney prefers the State Board to assign the tank number,please leave it blank. <br /> TF IS'111 1 RIS-SPONS1I3111TY OF 111E LOC AI,AGENCY"I"IIAT INSPIR—IS TFIE FAC:ILTIY TO WRII'Y TIIB <br /> ACCURACY C,'Y OIC'111 IN aOR 'I`ON. 'DIE LOCAL AGENCY IS RESPONSIBLE IaOk"I1IE`COMPIT`I'IC N,0F ImEr <br /> 'LO(:AL AG NC`Y USI1 ONI.'Y*INI OR YV PION IX)X AND FOR FORWARDING ONE FORM'A'AND ASSOCIN.11 ) <br /> FOgM'B'(s)"€O-11`1111'`FOLLOWING ADDRES`s, <br /> ST'A'DS OF C'AI;FORNIA <br /> " XI"E W,AIUR RIrSOURC'IN CON1701.I30ARD <br /> Dth'I:A P OCI INN(1 `IVR <br /> P.0,BOX 527.' <br /> PAF-AMOUNT,CA 90M <br /> > <br />