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ti <br /> INSTRUCTIONS FOR COMPLETING FORM'I3' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS, PERMIT C't1ANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLIC'.ANI'or the LOCAL AGENCY UNDERGROUNDTANK,. <br /> INSPE(TOR. <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 OF FORM:"MARK ONLY ONE rI'I%* <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 I)BA or Facility name where the tank is installed. <br /> 1. TANK DESCRIP'17ON-C'OMPI.I3"I13 ALI.r1ti+MS-1F UNKNOWN-SO SPECIFY <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.25,000 or 10,000 etc.). <br /> H. 'TANK C.OM11WI S <br /> A. 1. If MOTOR VEHICL:Ei DUEL.,,check box I 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 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 /> III. 'TANK CONS'T'RUCTION-MARK ONE r11 1 ONLY IN IX)X A,T1,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PRO'lmvriON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> L Circle A if above ground;circle U if underground; and circle both if.applicable. <br /> 2. If UNKNOWN,circle; or if O'HIER,print in space provided. <br /> 3. Indicate the LEAK DEFECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEI`F(711ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON'TANK PERMANTN17 Y CIA)SED IN PLACE <br /> 1. ESTIMATED DATE IAS'T USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA%ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL.? Check 'Yes'or'NO'. <br /> A.PPLIC AN7:'MUST SIGN AND DN1E T11H 11ORM AS INDI(/\IED. <br /> IN81ItUC11ON FOR11113 LOCAL AGENC:IL S <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 Sta#e Board to assign the tank number,please leave it blank. <br /> fI'IS 1IHi RESPONSIBUXI'Y OF 111I?IACAL AGENCY 711NF INSPI:?C`TS I1IE FAC.IIITX TO VERIFY'11W <br /> ACCURACY 01711113 INFORMA7I1ON. 7IIE LOCAL AGENCY IS RESPONSIBLE FOR'I.11I3 COMPIJrI1ON OF TIIE <br /> *LOCAL AGENCY USE ONLY'INFORMNIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIN1E13 <br /> FORM"B"(s)TO-17117.FOI1.OWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STNI13 WNIER RESOURCES CONTROL BOARD <br /> C/O S.W.11 E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.IX)X 527 <br /> PARAMOUNT,CA 90723 <br />