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IN917L.UCHONS FOR CMPMING FORM '11' <br /> GENERAL INS'I'RUCIION&- <br /> L One FORM "B"shall be completed for each tank for all NEW PERW. I'S,PERMIT CHANGES, REMOVAL Sand;or any <br /> other TANK INIZORMAMON CT GE? <br /> 2. 'Phis form should be completed by either the PERMIll'APPLICANT or the I.00AL AGINCY UNDERGROUND TANK <br /> .r <br /> ,, ENSPIx('IYJR <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies, <br /> `MP OF FORM*MARK ONLY ONE rn-,A- <br /> .1. Mark an (X)Ja the box next to the item that best describes the reason the form is being clO- <br /> 2. Indicate the DBA or Facility name where the tank is installed, <br /> 1. TANK DF-SCRIVI'TON-COMPTICM.ALL r1'EMS-IF 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.A1370799). <br /> B. Indicate the name of the company t1lat manufactured the tank(ex.ACIME.TANK MFG). <br /> C. Indicate the year the tank was install'4,d (ex. 1987). <br /> 1). Indicate the tank capacity in gallons(c)l.25,000 or 10,000 etc.).,- <br /> 11. 'TANK COMIEKIN <br /> A. 1. If M(YI'OR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE 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). V <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 /> III. TANK(X)N-`;I'RUG17ON-MARK ONE rM.M ONLY IN BOX A,B,C&D <br /> 1. Check only one item inT4U.OF SYSTEIM,TANK MNITRIAL, INTERIOR LINING and CORROSION PRO`IFcri0N. <br /> 2. If OMER. print in the space provided. <br /> M PIPING INFORMIMON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTI-LER,print in space provided. <br /> 3. Indicate the LEAK DETEMION system(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DUMMON <br /> 1. Indicate the LEAK DEIMM I ION system(s) used to comply with the monitoring requirements for the tag��, <br /> VL MR)RMATION ON TANK PERMANENIVY C7,OSED IN PI ACE? <br /> 51 <br /> 1. E5171MA'113113 DNIT,LAST USED-MOVI1-I/YF."R(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA7d,\RDOUS SUBS5FANCE remaining in the tank(in Giallons). <br /> 3, WAS TANK FILLED WMI INFIRT MATERIAL.? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DiV17E11111 FORM AS INDI(WIM. <br /> IN,';I'RUCIION FOR'111E.LOCAL AGINCMIS <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 agenc3q, 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, <br /> , please leave it blank. <br /> Y17 IS TIM RESPONSIBIIJI-Y OFMIE LOCAL AGI:N('Y'IIIAT INSP U-NN ME FACILMY 1`0 VERIFY T1111 <br /> ACCURACY'OF"1711?INFORMAMON. '1111.1",OC AL AGENCY IS RUSPONSIBIZ FOR 11111 COMP11311ON OWITIE <br /> *LOCAL AGENCTY USE ONLY*INFORMSTION BOX AND FOR FORWARDING ONE FORM, *A"ANDASSOCINIVI) <br /> FORM'B'(s)TO TIM FOMOWING ADDRFL&S, <br /> 917A'11-� OF CALIT"RNIA. <br /> N MINTMOT,I )AR" <br /> CEN-17"R <br /> P,OIM 527 <br /> PARAMOUMF,CA 90M <br />