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17 <br /> IN,51'RUCITONS FOR COMPIR17NCo FORM'B" <br /> GENERAL INSTRUC11ONS- <br /> 1. One FOKNI "B"shall be completed for each tank for all NEW PERMr1-N,PERMIT CIIANGES, REMOVAI-S and/or any <br /> other TANK INFORMA'ITON CHANGE. <br /> 2. This form should 6e completed by either the PERMIT APPLICANT'or the LOCAL AGI.N. CY UNDERGROUND'TANK <br /> INSPECIIOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP-W?FORM:*MARK ONLY ONE MM* <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 /> I. TANK DF-SCRIP717ON-COMPLIffl!All.r11,2AS-IF UNKNOWN-SO SPUI-'IIT <br /> A. Indicate owners tank ID # -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.2.5,000 or 10,000 etc.). <br /> H. TANK CONrEN`VS <br /> A. I.- If MOTOR VI-.IIICLE FUEL,check box I and complete items B&C. <br /> 2. If not MOTOR VEHIC11FUEL,check the appropriate box in section A and complete items B& 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR V1711ICLE FUEL(if box 1 is checked in A), <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK CON,';'I'RU(:'IION-MARK ONE n-EM ONLY IN BOX.A,11,C&1) <br /> I. Check only one item inTYPE OF SYSTEM,"TANK MATERIAL, INI'ERIOR LINING and CORROSION PROTFcriON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING IMTORMNFION <br /> I. 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 /> 3. Indicate the LEAK DLIUC-nON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DlnVX,'ITON <br /> L Indicate the LEAK INITT-4CTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANFNIT.Y CLOSED IN PIACI? <br /> 1. ESTIMAJT�D DATE LAST'USED-MOINTFII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMA'T'ED QUANITrY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WrI'I I INF'.I<]-MA'ITRIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST'SIGN AND DA1UTIIE FORM&S INDICAITtl). <br /> INSTRUC!IION FOR THE LOCAL 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 (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 /> IT is TIIE REsPoNsiBulTy ownitt wcAL AGENCY THAT INSPECIN 111E FACT.I.117Y 170 VERHIVIIIE <br /> ACCURACY OF THE INFORMXIION. 771E LOCAL AGENCY IS RESPONSIBLE FORT11E COMPIJ,.-IION OF'I7IE <br /> "LOCAL AGENCY USE ONLY"INFORMKIION BOX AND FOR FORWARDING ONE FORM*A*AND ASSOCIATED <br /> FORM'B'(s)TO-171113 FOLLOWING ADDRESS. <br /> ,STATE OF CALIFORNIA <br /> ff)r�TMOL B0 <br /> ARI <br /> DATA PROCESSING CIW1`ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />