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1'q.S'rRU('F70NS FOR COMPLIN'ING FORM-Ir
<br /> GENF.RAL INs-rRucncNs
<br /> 1.. One FORM "B"shall be completed for each tank for all Nf,,W PERMI'l-N,PERM17V CHANGES, RI'l"�,4,f,iVe,,iS,�s'ii5"
<br /> otherTANK INFORMA71ON CHANGE.
<br /> 2. This form should be completed by either the PERWr APPLICANT or the LOCAL AGI-N(:Y UNDUR6ROUNDTANK
<br /> INSPIX71"OR.
<br /> 3. Please IST,,,. sir print clearly all requested information,
<br /> 4. Use a hams point writing instrument, you are making-3 copies,
<br /> 'FOP OF FORM.*MARK ONLY ONIz fTIW, *
<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 D1-SM, 1P`17ON-COMP117111 All,nT%LS-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(cx.A1370789),
<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. 1.987).
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.).
<br /> iii. TANKCONIIININ
<br /> A. 1. If MO-°'I7 VIiIIICI.,I3 FUEL,check box I and complete items B & C.
<br /> 2. If not -,-IOTOR VEHICLE FUEL,check the appropriate box in section A and complete items 13& 1),
<br /> B. Check the,appropriate box.
<br /> C. Check the type of MOTOR WHICLE FUEL(if box 1 is checked in A).
<br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C.A.S4, (Chemical Abstract Service
<br /> number), if box 1 is NOT checked in A.
<br /> III, TANK.CONS-MUC717ON-MARK ONE 1'I7FM ONLY IN BOX A,K C&D
<br /> I. Check only one item in TYPE OFSYS-.IE,\4,"TAMC MATERIAL,1,N71'ERIOR LINING and CORROSION PROTU"(110N,
<br /> 1 If Orf.'IJER,print in the space provided.
<br /> TV, PIPING TNMRMA:.'ION
<br /> 1. Circle A if above ground; circle 11 if underground:and circle both if applicable.
<br /> 2, If UNKN,;VVN,circle; or if 0111 SR,print in space provided,
<br /> 3. Indicate ih,-LEAK DF,TEC`I IONsystcm(s)used to comply with the monitoring requirctrew for!he piping,
<br /> V. TANK LEAK D1111 ITON
<br /> 1. Indicate LEAK DI..I'F,(.,7ION system(s)used to comply with the monitoring requirements for the tanl-.
<br /> V1. INF'ORM/VI1ON ON`TANK PERMANINIVY C1,OSED IN PIA(111
<br /> 1. ESTIMATED DATE LAST USM) - MON-111iYEAR (January, 1988 or 01/88).
<br /> 2. r:snM.AfFD QUANTITY of IWARDOUS SUBSTANCF remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED W17111 INERT NMA'117RIAL? Check'Yes'or WO'.
<br /> APPL1(:AN`1'MUST SI(.'-N AND DKI11 IM7 FORM AS INDICAITID.
<br /> IN,S`FRUC`I1ON FOR 11111[A)CALAGENCIES
<br /> The state undcn,round storage tank identification number is composed of the two digit county number, the ffircc digit jurisdiction
<br /> number,the sb,,digit facility number and the six digit tank number. The county and jurisdiction numbem are pi-cdetermined and
<br /> can be obtai'nc-d by calling the State Board (916)739-2421. The facility number must be the same as shown in forfn "A". -11,,c
<br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alpfial)ct. If
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> IT IS'171I3 RnSPONSIBUXI'Y OF11IF 1A-)CAL AGENCY 11ISF INSPVUI'SnIE FACIIr1`Y'IX)VERIFY'1711;
<br /> ACCURACY OF 111E INFORMN.110N. 111E ID(AL AG1.NCY IS RESPONSIBIX FOR 17111, COMPU317ON OFT11F
<br /> *IA)CAL AGI1,NCY USE ONLV I-NMRMA*IION BOX AND FOR FORWARDING ONE FORM*A*AND ASSOC1W.IT?j)
<br /> FORM'W(s)1OUIE FOUDWING ADDRESS.
<br /> STATE OF CAUFORNIA
<br /> SrXIII WX1`ER RESOURCES CUWROL BOARD
<br /> C/o sm.E-Rrs.
<br /> DATA PROCE-SSING OiNFITIR
<br /> P.O.ROX 5271
<br /> PARAMOUNT,CA(XYM
<br />
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