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-.4 <br /> IN,51'RUCIIONS FOR COMPLYTING FORM*W <br /> GENE RAI,INS1*RU MTONS.- <br /> L One FORM "B"shall be completed for each tank for all NEW PERMLIS,PI RMIL CIIANGES, REMOVALS and/or any <br /> otherTANK INPORMJVIION CIIANGIL <br /> 2. This form should be completed by either the PERMIT APP11CAN'For the IOCAI,AGENCY UNDERGROUND TANK <br /> INSPEC7170R. <br /> 3. Please type or print clearly all requested information. <br /> A. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM: "MARK ONLY ONI?r1MW <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 DBA or Facility name where the tank is installed. <br /> I. TANK DFSCRTIYIION-COMPIHrP,A11,n1WS-IF UNKNOWN-SO SPFnFY <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 /> 1). Indicate the tank capacity in gallons (ex.2.5,000 or 10,000 ac.). <br /> 11. TANK 1CONMiNFS <br /> A. 1. If MOTOR VI.,'IIICI,E FUEL,check box I and complete items B &C. <br /> 2. If not murm 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 NO'I'check-ed in A. <br /> Ill. TANK CONS17RUCJ1ON-MARK ONE fIEM ONLY IN BOX A,11,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,"TANK MATERIAL, LINING and CORROSION PROTEC'nON. <br /> 1 If OTHER,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 /> 1 If UNKNOWN,circle; or if OTHER, print in space provided, <br /> 3. Indicate the H7AK DETECHON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK IEAK DI?I7 <br /> 1. Indicate the LEAK DETEC'FION system(s)used to comply with the monitoring requirements for,the tank. <br /> V1. INFORMATION ON TANK PERMANEN11Y 0A)SW IN PLACE <br /> 1. F-S-11MATI",J) DATE,I.Agr USEi)-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ES`FIMA`IED QUANTITY of I-IAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS"TANK FII,I,ED WITH INERTIMATFRIAL.? Check 'Yes' or'NO'. <br /> APPI.ICANF musr SIGN AND DA11,1JUE FORM AS INDICWFED. <br /> IN91'RUCnON FOR 711E I.00AI,AGENCIF-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 State Board to assign the tank number,please leave it blank. <br /> I'LISTILE RESPONSIB111TY OF 111I:3 IOCAL AGENCY TI1ATINSPIX.n—17JE FAC1LrI'Y TO VERIFY 711E <br /> ACCURACY 011111E INFORMATION. TIIH I.00A1.AGENCY IS RESPONSIBIJ!FOR'I1W-COMPI1i110N OF`JTIE <br /> "LOCM.AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM *A"AND ASSOCINIV-1) <br /> FORM'B'(s)'M 711E.F011.0WING,ADDRESS. <br /> 917VIV OF CALIFORNIA <br /> grNIII WR'I'ER RENOURCF-S CONTROL BOARD <br /> C/O S.W.ILUP.S. <br /> DATA PROCESSING CENFFR <br /> P.O.13OX 527 <br /> PARAMOUNT,CA 90723 <br />