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IlNKYRUCYTONS POR CONW1171FINCI PYDRVI'Ts'
<br /> OWNTZRAL IN 1'1Ct3(AI1C:'dS
<br /> 1, One FORNI "B"shall be completed for each lank for all NEW PF,RMT,"-,
<br /> other'TANK,INFORMNITON CTIANGE
<br /> ')CAL AGFNC' U`
<br /> 1 this form�Jiould,be comp�ctcd byeither the PJiRMTFAPPJJCANTo!, V11
<br /> -equcsted isforlrlation�
<br /> 3. Please, tyr, ciewly 4 l
<br /> -1, Use a N�11J ,X)int-wrung instrumen, you are making 3 co des"
<br /> _)NLY ONE TTEM"
<br /> OP FORM:'MARK
<br /> 1. Mark an (X,in the box next to the item that best dcscribes, the reason the forn, is being comps:ted.
<br /> 2. Indicate tbc DBA'or Facility name where the tank is installed.
<br /> 1. IANK DE-SCRYPHON-COMPLIT171 All,T11W_S-IF UNKNOWN-SO SPMFY
<br /> A, Indicate owner:;tank ID If there is a tank number that is used by the owner to identify the lank(ex.. A137(77V),
<br /> B, Indicate the name of the company that njanufactured the tank(ex.ACME"I'ANK MFG.),
<br /> C. Indicate the year the tank was installed (�x. 1.987).
<br /> 1), Indicate ibe lank capacity in grallons(a-<. 25,000 or 14.E etc.).
<br /> A. 'TANK CON11WIS
<br /> A. 1, if 1,40'. `[C VE'RICLE check box I and complete items B & C
<br /> 2. I# not 1.�,Io`i'()R VEHICLE,FUEL, check the appropriate box in section A and ollnpict-, iterly B & 311
<br /> B. Check the appropriate box,
<br /> C. Check the l-, e of MO'I'(')R VEHICLE FUEL(if box I is checked in A).
<br /> D. Print tile "h-nnical name of the hazandous substanotstored in the lank and the C-A.S4. (Chcalfuil Abstrao "earn::
<br /> number), if box I is NO'I'checked in A.
<br /> IM -MARK ON1317.17M ONLY EN13OX A, B,C&1)
<br /> 1. Check oriv one item INJ'FIZIOR LININC; and
<br /> 2. If 0'111E',i?_ print in the space provided.
<br /> IV. PIPING INF()RM1,'7`QN
<br /> 2,
<br /> 1 lnd�,Oe LEAK DE'l 1 C:171100 lc'ed t,", with its root rrat."rinf' rfQcsir,,�Menl for lkiT
<br /> V,
<br /> llldic)lc 11 AK tvscd to colnplyvltbi IN,
<br /> r,` -AA'1'I0N CIN'I'ANK PURMANINIIN CLOSED IN PLAC1,"
<br /> DA'IE 1..AS1,USED- (Jalluary19,F's or
<br /> ()UAN'1'Yt'Y of PA/ARD(sUS SUBS"YANCE, rcnlaining in the lank (ill Ga"Pon",
<br /> 3. WAS J'A'4K PILLI'D `v l' MA'JI'MAL? Chcck, 'Yv_,'or'MY.
<br /> Al';'' IMU SY,iN'ANT)DA-171111"1k)RIM, AS INDT(WIl 1),
<br /> INEIRI lN FOR'H l"LOCAL AGI WOES
<br /> 1-he state und,,,,,,jound sloragC Lank is cotliposed of tile, two dilgil county
<br /> numl)er, !h """, ji-it facility number and the six dipjt milk nurnbcr. 'T'he county and jurisdiczion nunn',cis are
<br /> Can, be oblaifto"J by calling the State Board (916)739-2421. 'I`h�, facility nunabwr nlwsi be thcsinic asshown X firin
<br /> tank number may be assigned by the 'local agency; however, this nurnber must be ilmncric;dand cantina conga an
<br /> the local agent/y prcfenq the State, Board to assign the lank number, please: leave it black.
<br /> H'18'11It?RI?SPONSIBIIXT-Y OF IIIH JO(W,AGINCY 111AXINSPEC-PS111F FACHT17Y V)vl�,RMY'lTiF
<br /> 1J
<br /> AC( RACY LO
<br /> Ili INFORMN110N. '11111 CAL AGINCY IS RIESPONSJBIJ3 FOR'111F CIOMN11,170NI,0111'fi;Vl
<br /> *UXAL A(;i^NCY USE ONLY'INMRIMN11ON BOX ANT)FOR FORWARDING ONE,VORPA "A'AND ASSOCTA'11D
<br /> FORM'W(01'01111i,1k)1,1,OWING ADDRES.S.
<br /> S"VVIE OF CNIIIIORNIA
<br /> SI'A71371 WNIER RliSOURCEN C,0`1RO1,BOARD
<br /> C 0&W.F ERs.
<br /> V 'A '-jCfl I
<br /> INVI7 PRf ;-_�SING (-_VN`1-t`R
<br /> V,0, BOX
<br /> PAI"MOUNI-,(A(X77—n
<br />
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