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�► i <br /> IN9I1RUCnONS FOR COMPLETING FORM"W <br /> GENERAL INSTRUC`nONS: <br /> L One FORM"B"shall be completed for each tank for all NEW PER. . 1N,PERMrr CHANGES, REMOVAI:S and/or any <br /> other TANK INFORMNITON CHANGE. <br /> 2. This form should be completed by either the PERIyII 'APPLICANT or the LOCAL AGENC:Y ..N.AGROUND TANK <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing inst.runlent,.you are nla}ing 3 copies. , <br /> TOP OF FORM:"MARK ONLY ONE r11:IM" <br /> 1. Mark an(X) in the box next to the item that best describes the reason the farm is being;completed: <br /> 2. Indicatelthi 15Ak*r'F6ity name where the tank is installed. <br /> 1. 'TANK DESCRIVITON=COMPIZ17F.AI.I.,rJUMS-IF UNKNOWN-SC)SPECIFY <br /> A. Indicate ownets tank Il) #-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 /> 1). Indicate the tank capacity in gallons(ex.25,()00 or 10,000 etc.). <br /> II. TANK CONIVWIN <br /> - 'A <br /> A. 1.. If MOTOR VEHICLE FUM..,check box 1 and complete items B & <br /> if:,Atif hft3'I:oR'Vr,IIICLF 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 S;�vice <br /> number),if box 1 is NOT checked in A. <br /> ILL TANK C ONSTRUC:110N-:MARK ONE 171-13M ONLY IN BOX A,B,C.&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,I4'ITRIOR LINING and CORROSION PROTI3MON. <br /> 2. If OTHER,print in the space provided. <br /> IV, PIPING INFORMA110N <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2 If.UNKNOWN,circle;or if OTHER,paint in space provided. <br /> 3. Indicate the LEAK DETECITO;N system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE l^ <br /> 1. ESTIMATED DATE LAST USED-MONIII/YEAR(.January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTI'T'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), f' ) <br /> 3. WAS TANK FII.,LED W rn I INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLIC:ANr MU%I'SIGN AND DA113 THL FORM AS INDICK119). <br /> INSIIRUC11ON FORME 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, redetermined and <br /> can be obtained by calling the State Board (916)739-2421. The facility number must he the same as shown in form "A". The <br /> ;tank number t*y 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 TIfE RESPONSIBlit rry OF nm LOCAL AGENCY'LI-IAT INSPEC:IN TILE FACILITY TO VERIFY TIJM <br /> ACCURACY 017111H INFORMATION. 'ITIS I.,OC:AI.,AGENCY ISS RII,SPONSI131l,'11(:)R'TII1?C'OMPI,TpI1ON OF`III1? <br /> 'LOCAL..AGENCY USE ONLY"INFOIRMA111ON BOX AND FOR R)RWARDI:NG ORIF FORM"A"AND AS,C)CIA'IVD <br /> FORM'B'(s)TO nIE FOI1.,OWING ADDRESS, <br /> STATE;OF C,A11FOORNIA. <br /> srxll1 WA I :;R K11 101JkC11S 'It0)I<JX)ART) `'t <br /> P.0.BOX 527 <br /> PARAMOUNI',CA 90`72.3 <br />