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0 <br /> GINFRAL PRUC MONS; <br /> 1. One FORM"B"shall be completed for each tank for all NEW PFRW IN,PERMrr CHANGES,S, REM VAI,and/or any <br /> other TANK INFOR TTON CIEA.NG <br /> 2. This form should be completed by either the PEW41T APPU" I"or the LOCAI.ACII7NC`Y UNDERGROUND'I'ANK <br /> INSPI:= IC <br /> 3. Please type or print clearly all requested information. <br /> 4, Use a hard n wffsting instrument. making 3 c <br /> t,! <br /> TOP OF F6 AY,ONLY Y ONE I"rl:W <br /> 1. ;dark an (JC)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 /> t. TANK 131:. 'R I6 -16MPIHMI ALL MiMS-IF UNKNOWN C7 -SO SPFnFY <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.). t <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. 'E'ANK CX) IS <br /> N\ <br /> A. 1.If MOTOR VFMIC LI FUEL,check box I and complete items 13&C. <br /> 2. If not MO`I'C)R VEHICLE FLIED,check the appropriate box in section A and complete items LB& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE,FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stared in the tank and the C.A.S. . (Chemical Abstract Sc�ice <br /> number),if box I is NOT checked in A. <br /> III. TANK C ONS r RUC"1 ION-mARK ow num oNiy IN BOX A,I C&I3 <br /> 1. Check only one item in TYPE Of, SYSI'E ,'I ANie MATI IZIA1.,I..VI`ERI0R LINING and CORROSION PRO'I`E ., ON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING(1.. IC NIIC N <br /> I. Circle A if above ground; circle E3 if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle, or if 01HER,print in space provided. <br /> 3. Indicate the LEAK I?T:T CITC3N system(s)used,to comply with the monitoring;requirement for the piping. <br /> V. TANK LPAK III?"FEC 1710 <br /> 1. Indicate the LEAK DETI. ON systems)used to comply with the monitoring requirements for the fa`ttk. <br /> VI. INFORMAMON ON TANK mk ANLim Ct5 IN PIA( <br /> 1. ES'11MAI'ED BATE LAST USED-MOXITI/YEAR(January, 1988 or 01/38). <br /> 2. FSTIMATED QUANTITY of IIAd'AItDOUS SUBSTANCE remaining;in the tank.(in Gallons). <br /> 3. WAS TANK FILLED WFrII IllEWI'I AT°I RIAI,?Check'ales'or WO'. <br /> APPI..(` CJSI"sic Am)DATE THE FORM AS INDIC-NM33, <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 arepredetermined and <br /> can be obtained by calling the State Board(316)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 merit 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 /> 1"I'IS THE iL )NSTIIILYI"l OF"IME 1,OCAL AGENCY Y TI AT°INSPECIN 1111i FACIL TO VERA 'IIID <br /> ACrC U C OF 17111 INFORMMIION. TIIE?LOC'AI.AGIsN(7Y IS RESPONSIBLE It C) ,'II II?C OMPlIn IC1 OF 11111 <br /> *LOCAL AGUSE C) Y*1NP()RMXJ7ON BOX AND FOR.FORWARDING ONE FORA 'A*AND ASS C. 'I`I D <br /> FORM "(s)T()T IE F01. ,0 INN ADDIUM. <br /> SYNtli OF CAIJFORNIA <br /> SI'Alli!W T R LRCMs CONMROL BOARD <br /> C/o& P,S <br /> DATA PEC M&S G(1 I'ER <br /> P.O_BOX 527.. <br />