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Ipk;TI'I1LfGI1CSdS FOR(X)N4`IJ I'INCi FORM 'B'
<br /> GE'NERAL IN9FR J("I'If)Nl o
<br /> L One EaOIC4 "13" shall be completed for each tank for all NIPN PERNIT'I'S,P U'RMCIIA.N SHS, RFMC) AIS and/or any
<br /> other TANK IN1k)I2MA`I1C)N CHANGE,
<br /> 1 This form should be completed by c i€lher theFR 'APPI:T("A I Or the LOCM,AGENCY IJIVI ERGROUNT)T" N
<br /> 1NSPW,I O
<br /> 1 Please type or print clearly all requested information.
<br /> 4. Use a hard point writing instrument,you are raking:3 copie .
<br /> 'TCT OF FORM:*MARK ONLY ONli CI°i MM'
<br /> Mark an ., in a;,aa; 1)c)x nc,x', to l;c .t r. hat ct s`: desc ;bc ..: .,<.,oii the firm is ben-egmpieted,
<br /> Indit ue V- DBA or I ae:liav °rhe i anf,is installc,E',
<br /> 1. TANK DFS(."RTP I'lt)tN-COMP[JflT:,ALL IFI i" IF UNKNOWN
<br /> , Indicate c�viic:ts tank ID 9-If there t,,to tank number that is 'by the owner to identify the tank(ex:A1370789).
<br /> 13. Indicate lfc name of the company tha.m:Awfactured the tank ACME.TANK MFG.).
<br /> C, Indicate tht, year the tank-,vas installed t x. 1967).
<br /> 1), Indicate the, tank capacity in gallons(cy . ',000 or 10,M)etc.).
<br /> 11. TANK CON17W. IN
<br /> A. L If MOTOR VEHICLE FUEL, check box 1 and complete items B & C.
<br /> 2, 11 not MO'J'OR VE TICLT.FUYLI check the appropriate box in section A and complete items 13& D.
<br /> 3, Check the appropriate box,
<br /> C. Check the type of f,1 J'I'OlI V ITIIC11i FUEL(if box t is checked in A),
<br /> T), print the chemical name of the hazardous substance scored in the tank and the C,A.S,#, (Chemical Abstract Service
<br /> number), if box 1. is NO"I'checked in A,
<br /> ITL TANK CON;3[TC 1G I'ICSN-MARK ONE rIEM C3PILY 1N 13m A,11,C&I3
<br /> L Check only One item in'I"IIE 01""TYSTEM.TANK N1r TE.RIAL, IMUNZIOR LINING and CORROSION PROTTs'C'I10N,
<br /> 2" If 0'111FR,print in the space
<br /> provided—
<br /> 1, Circle A if above ground; circle If if underground;and circle both if applicable:'
<br /> 2. If UNKNOWN, circle; or if()T 111-:,Z, print in space provided,
<br /> 3_ Indicate the LEAK cased to comply with the monitoring requirement for the piping
<br /> V. TANK LEAK DI1ITX711()N
<br /> 1, Indicate the LEA DE'TECI-ION system(s) used to comply with the monitoring requirements for the tank.
<br /> VI, I1VFORMSPION ON TANK PERMA i.NPI: CU)SED IN PIAC E,
<br /> 1, ES't'1MA'I`ED l)NI'I:' L(AS"I'IJSI.,,. -MON'nl/Y AR(January, '1988 err fl'I/8€t).
<br /> 2. E141IMATE'D QUANT'1TY of ITAVAItI:)O[)S St)BS`I'ANC:II renaar`ning in the tank(in Gallons).
<br /> 3. WAS TANK F111f,J)WITH INE:I2'I`MA711RIAL> Check 'Yes'or'NO'.
<br /> APPII()AN1'ML1'�;I'SIGN ANIS DNIE'17113 FORM AS INDI(WI.T0, .
<br /> IN,51'R 7('I`ON I1OR`nJE LOCAL AG1;II°CII:US
<br /> "I'he 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". '.I'he
<br /> tank number may he assigned by the local agency,however,this number must be numerical and cannot contain an alphabet, If
<br /> the meal agency prefer;the.State.Board to assign the tank number,please leave it blank.
<br /> rr IT 171111 RE SI'ONSI13T XI`s' Cllr T"FI T LOCAL AGENCY TIIAT INSPI" '1`1E I1ACJI.XrYTO VERIFY 11II:a
<br /> ACCU C,,; 01,1 1'111;INI )_ A`IJO,I-, 1"I1H LOCAL AGEN(, IS RIftSPONSIBLI;FOR T"111?€OMP1.,ETION OF-ITT
<br /> "LOCAL AGENCY 'C)aNLY'
<br /> US FN.I"O MA1'10N BO IS FOR O ONEF FORWARDING ONE FORM"A$AND AI ISOCMIA€"I,,T
<br /> FORM -(s)T 1-III,FC)LL0 � G AD3 T _
<br /> SPAT )Fa CAtaFORNIA
<br /> 1`A'IT<WK",'-r? 1 .It t C 1ci Ca II° .C)1, lit) RL1
<br /> P.O.I)Cy7C 52-7
<br /> ISA MOUNT`,CA IXY723
<br />
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