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IN,1517CUCTnONS POR COMPIHITNCY FORM*Ir <br /> GENERAL.INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMrr CHANGI.I.S, REMOVALS and/or any <br /> other'll'ANK INFORMA`170N CHANGE. <br /> 2. This form should be completed by either the PERM171'APPLICANT or the LOCAL AGENCY UNDERGROUND 7ANK <br /> I MSPECTOR. <br /> 3. Please type or print clearly all requested informiition. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 1XV OF FORM:'MARK ONLY ON13 YI'IW* <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 lank is installed, <br /> 1. TANK DESCRIVITON-.COMPIHI'L?ALI.r1`EMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID# 7 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.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex.25,()00 or 10,000 etc.). <br /> 11. TANK CONJT94rS. <br /> A. 1. If MOTOR VEITICIA.,"FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEI-IICI,F 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 VEIIICI,I.:,'IUFI,(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 1.is NOT checked in A. <br /> HL TANK C-ONSTRUC7110N-MARK ONE.rllM ONLY IN,BOX A,B,C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA'11ON <br /> 1. Circle A if above ground; circle U ifunderground' and circle both if applicable. <br /> 2. If UNKNOWN,circle, or if OTHER, print in space provided. <br /> 3. Indicate the LEAK DF ITXTFION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUFFX-11ON <br /> 1. - Indicate the LEAK 1311 t1`C -system(s) used to comply with the monitoring requirements for the tank. <br /> .11`10N <br /> VI. INFORMATION ON TANK PERMANITNnY CLOSE0 IN PLACE- <br /> 1. F:Sl'lMATFD BATE EAST'USED- MONrill/YEAR(January, 1988 or 01/88). <br /> 2. E.911MATED OUANHITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH I INFIRT MATERIAL? Check'Yes' or'No '. <br /> APPLI(YiN17 MUSI'SIGN AND DAIS ITIE FORM AS INDICAT`FD. <br /> IN5172U(717ON FOR TIED LOCAL AGF N01N <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 lank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)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 agency prefers the State Board to assign the tank number, please leave it blank. <br /> rr is Tim RESPOINSIBUX17Y OF TIIE LO(AL AGENCY111ATINSPE(71N TIIE FACILITY'll)VERIFY'11111 <br /> ACCURACY 01711fE INFORMJV110M T1IE LOCAL AGENCY IS RESPONSIBLE I FOR'IIIE COMPLINION OF'11111 <br /> *LOCAL AGENC`Y USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM*A*AND A'S-SOCIA'ILl) <br /> FORM'B'(s)TO 11111 F0I.1,OWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> SF)VIT!WAILER RESOURCES COWIROL BOARD <br /> C/o&W.E.E.P.& <br /> DATA PROCESSING CER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />