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� INSTRUCTIONS FOR COMPLETING F(OR��»K3" ' ^ <br /> - <br /> GENERAL INSTRUCTIONS: <br />/ <br />� l One FORM ^8^ sha|l be cumwieted for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMAd[ION CH�ANGE <br />� <br />' 2 <br /> Th form should be com�leted by either the PERMIT APPLICANT or the LOCAL AGENCY O TANK <br /> ` INSPECTOR, <br /> , 3., Please type or print clearly all requested information, <br /> .4[ Use o hard point writing instrument, you are making 3 copies, <br /> . <br /> TOP OF FORM: 'MARK ONLY ONE ITEM'' <br /> ' I, Hark 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 /> T. TANK DESCRIPTION - CONP[ETE ALL ITEMS - IF UNKNOWN ' SD SPECIFY <br /> A. Ind1co0 owners tank IU # If there is a tank number that is used by the owner to identify the tank <br /> (ex, AB75780) <br /> U 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. 25,800 or 10,000 etc.) <br /> IT . TAAK CONTENTS <br /> A, I IF MOTOR VEHICLE FUEL, check box l and complete items D & 0 <br /> 2 If not M0TOR VEHICLE FUEL check the appropriate box in section A and complete items 8 & D <br /> ^ . <br /> B. Check the appropriate box <br /> C Check the type of MOTOR VEHICLE FUEL (1f box l is checked in A) , <br /> D Print the chem1col name of the hazardous substance stnred in the tank and the C A 3 0 (Chemic8l <br /> Abstract Service number), if box l is NOT checked in A. <br /> TTI , TANK CONSTRUCTION - MARK ONE ITEM 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 /> I If DTHER, print in the space provided, <br /> ' <br /> IV. PIPING INFORMATION <br /> Y ` Circle A if above ground circle U if underground and circle both if applicable. <br /> ' <br /> 2 If UNKNOWN circle: or if OTHERprint in snace provided <br /> 3 Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping <br /> ^ <br /> V. TAW LEAK DETECTION <br /> l Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank, <br /> ^ VT, INFORMATION ON TANK PERMANENT[/ CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED MONTH/YEAR (January. I988 or 01/88) <br /> ` 2 ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (1n Gallons), <br /> 2 WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO' <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. _ <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The state underground storage tank identification number is composed Of the two digit county number, the three <br /> digit jurisdiction number, the six digit facility number and the six digit tank numb6r. The county and <br /> jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 227-4303. The <br />' <br /> facility number must be the same as shown in form ^A^ The tank number may be assigned by the local agency, <br />| howe»er, this number must be numerical and cannot contain an alphabet If the local agency prefers the State <br /> Board to assign the tank number, please leave it blank. <br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE ' <br /> _INFORMATION. THELOCAL AGENCY IS RESPONSIBLE FOR TVE COMPLETION OF THE "LOCAL ABENCY USE ONLY' INFORMATION BOX <br /> AND FOR FORWARDING ONE FORM ^A~ &ND.AASDCIATEU FORM ~B~(s) TO THE FOLLOWING ADDRESS, <br /> �Al <br /> ' <br /> ' <br />