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<br /> IN,1n UC CIONS IIOR COMPIHIING I "B"
<br /> GEMIRAL INS71RUCITON&
<br /> 1. One FORM"B"shall be completed for each tank for all NEW PE TIN,PERMIT CHANGES, REMOVAUS and/or any
<br /> otherTANK liZORMA11ON CHANGE
<br /> 1 This form should be completed by either the PERMIT PPLI N'T or the LOCAL AGFNCY UNT?T?1d(SICCyUND"I° T
<br /> INSP _ IY)I
<br /> 3. Please type or print clearly all requested information.
<br /> #, Use a hard point writing instrument,you are making 3 copies.
<br /> P OF FORM,"MARK ONLY ONE TI L<
<br /> 1. Mark an(X) in the box neat to the item that best describes the reason the farm is being c<ampleled.
<br /> 2. Indicate the DBA or Facility name where the tank is installed.
<br /> 1. TANK I)La. , IVI°TON-C() FLUE ALI,rMJ S-IF UNKNOWNm SC)SPECIFY
<br /> A. indicate owners,tank II)#-If there is a tank number that is used by the owner to identify the tank(ex.AB73789).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME"DANK 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 /> 11. "TAMC CON I LINTS
<br /> A. 1.If MOTOR VEHICLsi:i_t^`IJEL,check box 1 and complete items B&C.
<br /> 2.If not MOTOR VEHICLES FUEL,check the appropriate box in section A and complete items B& D.
<br /> I1. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE E['[JEL(if box.1 is checked in A).
<br /> 11 Prmt the chemical name of the hazardous substance stored in the tank and the C.A.S.i#. (Chemical abstract Service
<br /> number),if box"t is NOT checked in A.
<br /> III.. TANK C ON< T.IC.II"ION-MARK ONE ITEM ONLY IN BOX A,T3,CP&I)
<br /> 1. Check only one item in TYPE OF S"YST1IM,TANK MATE RI L,INTERIOR LINING and CORROSION IBRO IT"C."I`Ef: N,
<br /> 2. If OTHER,print in the space provided.
<br /> IV. PIPING INFORMAIION
<br /> 1. Circle Aif above ground; circle U if underground;and circle both if applicable.
<br /> . If UNKNOWN,circle; or if()°I°IIBR,print in space provided.
<br /> 3. Indicate the LEAK DI.3, "EJ(`pION system(s)used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK[1IrTT,(711ON
<br /> 1. Indicate the:LFAK DEI C`11ON system(s)used to comply with the monitoring requirements for the tank.
<br /> . INIURMA71ION ONTANK PI:? NI:$ ILY CLOSED IN PLACI.11
<br /> 1. I,5 IMK,17 IJ DA°I"I ST USED-MO I/'YI°. R(January, 1.988 or 01/88).
<br /> 2 13,,1311M.ATED QUA: TTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons),
<br /> 3. WAS TANK FILLED WITH INI.,RT MA'T'ERIAL? Check'Yes'or'N®°.
<br /> PPL K" ' US"°T°SIGN AND DX1HT1IE TOR ;AS INDKWFED.
<br /> IMSTRUCDON FOR 71W.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 predeterinitied 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 tray 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'I1-II:I RESPONSWILTIT OF'.171111 LOCAL AGENCY 1111AT INSPI:$ TIIE FAC"HXI`Y° 111"s IFY"711E3
<br /> CCU d)ir"I W,INFORMKIION. 7 I E LOCAL AGENCY IS RESPONS11311i I IZ'I11E CC) I. ::ITCTN OF ITIE
<br /> *LOCAL CliI.blCY LT"H ONLY"INITORMNIION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCINFED
<br /> TOR "I3"()TOI II:E?FOI.1,OWING ADDRESS.
<br /> A11!OF C",ALA
<br /> C/O S.W.LL ..P.S.
<br /> DATA PROCESSING(12G'ER
<br /> P:C).11C)K 521
<br /> PARAMOUN17,CA
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