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I'm-am <br /> INS'FRUCHONS lk,)R CON&LYNING FORM"IIS <br /> GENERAL IN'STRUC17ON& <br /> L One FOWM 'B"shall be completed for each tank for all NEW rERMY]fS,PERMIT"CHANGES, RIZ40VAI-S and/or any <br /> other TANK INFORMA11ON CID%NGE. <br /> 2. Phis form should be completed by either the PERMn'APPLICAN117 or the LOCAL AGE W <br /> -Y UNI)I!R(;ROVND TANK <br /> INSPEC7170R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrui I nent,you are taking 3 copies. <br /> TOP OF FORM "MARK omy ONE rnm <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form Is being corn ct d. <br /> 2. lndicate�the DBA or Facility name where the tank is installed. <br /> I. 'TANK DESCRWHON-COMP113M All,17FEMS-IF UNKNOWN-SO SPFX3FY <br /> A. Indicate ownersqk ID # -If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the namObf the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1%7). <br /> 1). Indicate the tank capacity in gallons(ex.75,000 or 10,000 etc.)" I <br /> 17,) 9 <br /> 11, TANK CON11WIN <br /> .A. I. if MOTOR VEHICLE FUE.L,check box I and complete items B & C. <br /> 2.If not MOTOR VIIIIICLE 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 1 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 /> 111. TANK CON';ZIRUCIION-ALAiM ONE nFM ONLY IN BOX A,B,C&D <br /> 1. Check-only one item in'TYPE.017SYSIEM,TANK M,1:17ERIAL, INTERIOR LINING and CORROSION PRO TFQ1:10N. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMS11ON <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable, <br /> 1 If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETEC'11ON system(s) used to comply with the monitoring requirement for the piping <br /> V. TANKI,EAK D1.'I13C.11ON <br /> 1. Indicate the LEAK DFATICA,I ION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANIW11LY C1,OS M! IN PLACE -56,97 ; <br /> I. EsTimAnu) DATE LAST USED-MONTIIJJYEAR(January, 1988 or 01/88). <br /> 2. 1:-zSnMrkTEDdUAN`1`ITY of IIAVAIU)OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 1 WAS TANK WrIll INERT MATERIAL? Check`Y&or'NO*. <br /> APPLICANT MUST SIGN ANT)DATE?IME 1k)RM AS INDICATED. <br /> INS-1'RUC11ON FOR'I1IF LOCAL AGINCIES <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 contiiji an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> rr is wE mpomsmitn"y OF'17113 LOCAL AGINCY71TAT INSPEC'I'S 17W FAC11JrY TO VERIFY'nIE <br /> ACCURACY OF 111E INFORMATION. '11111 el-OCAL AGENCY IS RESPONSIBIM FOR 11111 COMPLE]ION OF THE <br /> "LOCAL AG1.NC`Y USE ONLY"INFORMA110N BOX AND FOR FORWARDING ONE DORM"A'AM)ASSOC11VIIII) <br /> FORM-B-(s)TO llffl FOLIA)WING ADDRE&S. <br /> S F <br /> IWIV OF(7/k,11TIORNIA <br /> CI'NN 11 <br /> PARAMOUNFI-,CA%KM <br />