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INSFRUCIIONS FOR COMPI X-1i I NO FORM'Ir <br /> GENERAL.INS-I'RUC.IIONS: <br /> 1, One DORM 'B'shall be completed for each lank for all NEW PERMITS,PERMIT 01ANGES, REMOVALS and/or any <br /> other'17ANK INFORMNLION CIJANGE. <br /> 2. This form should be completed by either the PFRmrr APPUCAN'Tor the IOCAT,AGENCY UNDERGROUND TANK <br /> INSPF,CI'OR- <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 ONIY ONE rmm" <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 1 Indicate the DBA or Facility name where the tank is installed, <br /> I. TANK DESCRIP11ON-(IOMPUTW,All.n'EMS-IF UNKNOWN-SO SPF"FY <br /> A. Indicate owners tank 11.) #-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. 1.987). <br /> D. Indicate the tank capacity in gallons(ex.2-5,0(X.)or 10,000 etc.). <br /> IL TANK(X)NI1VFS <br /> A. 1. If MOTOR VI I1ICI,E FUEL,check box I and complete items B&C. <br /> 2. If not MOTOR VEIIICI,E 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). <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 Nur checked in A. <br /> III. TANK CONFFRUCIION-MARK ONE rrEm ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OFSY,51'EM,TANK MATERIAL,INrIT"RIOR LINING and CORROSION PROTECTION. <br /> 1 If ULMER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2, If UNKNOWN,circle; or if O'ITIER,print in space provided. <br /> 3. Indicate the LEAK I)THTECLION system(s)used to coniplyxrith the monitoring requirement for the piping. <br /> V. TANK LEAK DiTiwnON <br /> 1. Indicate the LEAK sy-item(s) used to comply with the monitoring requirements for the lank. <br /> V1. INFORMA11ON ON TANK PERMANEN11,Y 0,0SED IN PLACE <br /> 1. 13.1"11MATEJ) DATE, 1,Asr usj,,.,I)-MOINIIII/YEAR(January, 1988 or 01/88). <br /> 2. ES-rIMATED QUANITTIN of IWAIWOUS SUBSI'ANCE remaining in the tank(in Gallons). <br /> 3, WAS TANK FII1FD WITH INER"I'MATERIAL,? Check 'Yes'or'NO'. <br /> APPLICANI'MUST SIGN AND DA711,1111P FORM AS INDICKIL0, <br /> ilslmucnON FOR'17113 IA)CAL 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 predetermined and <br /> can be obtained by calling the State Board (916)739-2421. The facility number nuist be the same as shown in form "A". '111c <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 State Board to assign the tank number,please leave it blank. <br /> IT ISn-111 RUSPONS11311-11T Oil TIIE IOCAI.AGENCY IIIE FACIL171"YTO VERIFY IIIE <br /> ACCURACY OF ITIE INFORMN110N. TTIF IDCAL AGENCY IS RUSPONSIBIli MR'IIIF-COMPI1rI1ON OF 1111? <br /> AGFN(7f USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM *A"AND ASSOCIATED <br /> FORM'B'(s)TO 111E FOIJ.OWING ADDRESS. <br /> S`FXIV 017 CALIFORNIA <br /> S`17NII?WA7(1`R RU'SOURCUS CONFROI,BOARD <br /> C/O S.WJU-P.S. <br /> DATA PROCUSSING CtWFFR <br /> P.O.BOX 527 <br /> PARAMOUNI',CA WM <br />