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INS'rRUCIIONS FOR COMPUEFING FORM*Jr <br /> GENERAL,IN517RIX-17ONS: <br /> 1, One FORIM "B"shall be completed for each lank for all NEW PFRMrI`S,PER CHANGES, REMOVAUS and/or any <br /> other"T INFORMA'IION('77-1ANGE. <br /> 2. This form should be completed by either the PERmr1`APPI1CiWI'or the IOCAI.AGENCY UNDERGROUND TANK <br /> INSPFCFOR. <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'FOP OF FORM: "MARK ONIY ONE rI`FM <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 DFSCRIPTTON-COMPIATIT,ALL rlEMS-W UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) # -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.ACMETANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1.)87). <br /> D. Indicate the tank capacity in gallons (ex. 15,000 or 10,M)etc.). <br /> 11. TANK(X)N71.!N15 <br /> A. 1. If MO'I'OR FUEL,,check box 1.and complete items B &C. <br /> 2. If not MOTOR VEIIICI,E 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 I 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 /> 111. TANK CON'FFRUC11ON-MARK ONE rlTiM ONLY IN BOX A,B,C&D <br /> 1. Cheek only one item in TYPE OI'SYS'T'EM,TANK MATERIAL,PTl`ERIOR LINING and CORROSION PROTECTION, <br /> 1 If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <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 I..EAK DETECHON systern(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK I,EAK Dl.nl!CnON <br /> 1. Indicate the LEAK DE-FEC'l I IONsystern(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMA31ON ON TANK PERMANEN171M CLOSED IN PLACE, <br /> 1. ES'I1MA111) IWIT,[AST USED - MON`l`ll/YF'.AR(January, 1988 or 01/88). <br /> 2. ESTINVVIUD QUANn'ry of RZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK Fll.I,FD WITH INERT"MA'ITRIAL? Check 'Yes' or'NO'. <br /> APPLICANI'MUS17 SIGN AND DA111'1711E FORM AS INDICW17ED. <br /> INSrRU('IION FOR 17TH WCAI.,AGENCIES <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 are predetermined and <br /> can be obtained by,calling the State Board (16)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 must be numerical and cannot contain an alphabet. If <br /> the local agerwy prefers the State Board to assign the tank number,please leave it blank. <br /> rl'IS TI-1E RESPONSIBlIXIT 01211Th I.00AI.AGENCY TTIATINSPIX71S 711E FACILT71-Y TO V17IRT17Y 11111 <br /> ACCURACY OF 1111i INFORMA71ION. 'nIE I.00AI,AGENCY IS RESPONSIBI.Ii FOR'IIIE COMPIJ.r.I1ON OF 111E <br /> "UDCAI,AGENCY USE ONLY*INFORMATION[4OX AND FOR FORWARDING ONE FORM'A'AND AW)CIA'IED <br /> FORM'B'(s)TO-11JE FOIJ.OWING ADDRESS. <br /> SPAT F OF CALIFORNIA <br /> SrNIV'WJVI`ER RIISOURCUS CONTROL BOARD <br /> C/O S.W.RE.P.S. <br /> DATA PROCESSING CENFER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90'M <br />