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INSTRUCnONS IUR COMPLMNG 'ii' <br /> GENERAL . rRC3 .'IO <br /> 1. One FORM"B"shalt be completed for each tank for all NFW PE I'N PERMIT C:IIANG S, REMOVAI.1S and/or any <br /> other TANK INP R £)N C:IIANG 9 <br /> 2: This form should be completed by either the PPAWr APPUCANT or the LOCAL AGMCY UNDERGROUND TANK <br /> INSPIXXOPL <br /> 3. Please type or print clearly all requested information. <br /> 4. €Tie a hardpoint writing in rumenN you re�.�iaking 3 espies, <br /> 1 >t r ,� a`, kot <br /> �.. <br /> TOP OF FORM:'MARK ONLY ONI?mm <br /> 1. Mark an (X) in the box next to the iters 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. TANK 1)I- () '-.r ." IST .a 4 ALL MWS-'B-P UNKNOWN-SO SPFX3FY <br /> A. Indicate owners tants IIS # -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,ACMiF.'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, etet,). <br /> IL. TANK CX)N'n!N`17i <br /> A. 1.If MOTOR VI:IIICI, FU13t,check box I and complete items II&C. <br /> 2. If not M01'OR VEMICI.E L'U L,check the appropriate box in section A and complete iters B & D. <br /> B. Check the appropriate box. <br /> C: Check the type of moTOR VEHICLE I=UEL(if box I is checked in A). � <br /> I). 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 C.'O r RC CHON-MARK 0 i rmm ONLY A,II,C;&Id <br /> I.. Check only one item in TYPE OI'SYS'F NC TA. MATERIAL,IN'I`ERIOR LINING and CORROSION PRO`I'I- , ON. <br /> 2. If OTIIER,print in the space provided. <br /> V. PIPING IM70RMATION <br /> I. 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 LE.AIC I)I 7'E , ON system(s) used-to comply with the monitoring requirement for the piping. <br /> V. TANK IMAK DErIMC11ON <br /> l: Indicate the LEAK D E'ECTION system(.-,)used to comply with the monitoring requirements for the tank. <br /> VI. FO TION ONTANK PERMANFLN11M CMOS10 IN PLACE <br /> 1. ESTIMATED BA'I'T;I..AST USED-It10N`I'II/'YI AR(.tanuaty, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA7ARDOUS SUBS'I'ANCE remaining in the tank(in (;allons). <br /> 3. WAS TAMC I'ILI.EL}wrni INERT 4//�1'ERIAL7 Check'Y'es'csr'NO'. <br /> APPLICANI'musr SIGN AND DKI11111E FORM AS INDICNI'ED. <br /> FnIS "RUC HON I?OR TIII? L AGENCJIt 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 anis jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (e)16)739-2421. The facility number must be the same as show=n 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 IST11[1 RESPONSIBUXLY OIC`I 111 LOCAL AGENCy,IIIAT It0'SI"FcIs I II.I71icli `i'£)` FRII 'rim <br /> ACCURAC X OF'11113 INIURMA7170N. ITIE LOCAL AGEW(Y IS RESPONSIBLE FOR ITIS C.0MPLIN ION OF'I7II$ <br /> 'LOCAL AGfNC1Y USE ONLY' s£)RRA7110N W)X AND FOR IX)R ARI)IN(:s ONE F()R 'A'ANIS&SSOC. 'IMD <br /> FORM'B'(s)713 17 IE FOLLOWING AIYCIIRI'sS.S. <br /> SPATE?OF CAIJ13ORNJA <br /> CATIs WXHiR 1S IIR(MS C;0 'ROL BOARD <br /> C/O S. .E ap Sa <br /> D/VrA PR.00 SSINC1 C;I:e II:?R <br /> P.O.I3OX 527 <br /> PARAT O 4r, <br /> J <br />