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I tSI`RI7 _ O S MR C"C) P :. tNG I *Ir' <br /> L One FORM"B"shall be completed for each tank for all NFW`PlIRWIN,PERMIT CHANGUS, RIEMOVAI S and/or any <br /> other TANK INFORMA17ON CHANGE % <br /> 2. This form should be completed by either the PIAVrr Appu(ANr or the LOCAL AGENCY UNDERGROUND TANK <br /> I SP1 <br /> .' 1 Please type or print clearly all requested information. <br /> 4, Use a hard oYsst nrumerx3� ca ale king 3 epi <br /> .. . .� <br /> TOP OF ONLY CD 1?17171IM' <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 1 Indicate the DBA or Facility name where the tank is installed. <br /> I. I)1 Ca121 IC) - I. .. .r ALL rFLTMS«TIt UNKNOWN-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 /> 13. Indicate the name bf the company that manufacturedthe t k.(ex. ACMI: FANK i4/FG.). <br /> C. Indicate the year the tank was installed(ex.1987). n. <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,OW etc.). ` <br /> II. TANK a I'ka <br /> A. 1.If MOTOR VEHICLE.17U.F1,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 B& 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 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;C3 PRUC:TICD ®MARK.ONE rrFm oNi x IN 13OX A,13,C&1) <br /> 1. Check only one item in TYPE OF S'YSI`EM,'TANNIC MATERIAL, I.NI'IE,RIOR LINING and CORROSION PROT EC'I IC)M <br /> 2. If OTITEP,print in the space provided. <br /> ISA PIPING INI*CDR 'PIO d s <br /> 1. 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 /> 1 Indicate the LEAK L3F11"C711ON system(s)used,to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK 1)111 C71`ON <br /> 1. Indicate the LEAK F? ON system(s) used to comply with the monitoring requirements for the tank. <br /> L 1NI1ORMA`nON ONTANK PERMANENFLY CII,CDS 1)IN PI-ACE <br /> 1. E>STIMNF'EED DA I.A91.I USED-MON`1TF/YI.-:AR(January, 1988 or 01/88). <br /> 2. ESTIMATED C2UANI`I'I`Y of IIA7ARDOUS SUB SUANCE remaining in the tank(in Gallons). <br /> 1 WAS"TANK hILLEIIt WrIll INEWI'MN.rERIAL?Check'Yes' or`[O% <br /> APP .1(" T musT SICK ANT)TDNFE ITH!"FORM AS IN DICA"I I), <br /> i <br /> S'TRUC'TIC3 I7t7R i III?LOQU.,AGENCIES <br /> x <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 number are predetermined and <br /> can be obtained by calling the State Board(916)739-2421. "I'he 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 /> 1"T IS 17111 R SIBIIXI'Y OF711E I AGE CY TI{AT I SPECIIN TIIH FAC1II. I Y TO VERIFY°1 111 <br /> ACIC.0 C`Y 01111 H INFORMATION. 'ITIiE LOCAL AGENCY IS RPNTONSIBLE FOR°111E3 C°CD PI f3I1ON OF"TITS <br /> 'LOCAL.AGf24C>'Y USE,tD .N*INFORMATION BOX AND I R FORWARDING ONE,IN)RM'A"AND&SSOCIA7110 <br /> DRM,'IP(s)11)1 111 I OI1,t3 I G AI)IID < S. <br /> ,5rA:rF.OF LIFO 1A <br /> AT1"s Al R RESOURCIN CA) Cil, A. <br /> DATA PRC)t>'ir&rSING C:11IN"HiR <br /> P.O.BOX 527,„ <br /> —711 <br /> P U <br />