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<br /> INSL'RLJCI7()NS ICOR C;UMPI.LTTIN(i FORM"I3" ,
<br /> GI?NI 3RAI.INSTRUE'I'I ONS:
<br /> i. One T'ORM"B"shall be completed Car each tank far all NL71Y PERMI"I','i,PERMCI'CIIANGI7S, RPMOVAIS and/ar any
<br /> other TANK INI70RMATION CHANGE.
<br /> 2. This farm should be catnpletcd by either the PIRMTI APPLICANT ar the IX)E:l1.I.AE:,I3NE."Y LLNDI?R(iR()UND'TANK
<br /> INSPI?CI'C)R.
<br /> 3. L'lcasc type ar print clearly all requested infarmat'ion.
<br /> 4. Use a hard paint writing instrument,you are making 3 copies.
<br /> '.I'OP OIC I�C)RM: "MA.RK()NI I'ONI:?TI7?M"
<br /> L �•3ark an{X)in the box next to the item khat best describes the reason the form is being compketed.
<br /> 2. Indicate the DBA car Taacility name where the tank is installed.
<br /> I. TANK DI:.+CRIP'ITON-CC)MPLI?'I13 AI.,I.I'I'I?MS-IP UNKNOWN-SO SPP.C�II7X
<br /> A. Indicate owners tank It)# -If there is a tank number that is used by the owner to identify the tank {ex.AB707A9).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACML'1ANK MIG,).
<br /> C. Indicate the year the lank was installed (ex. 15A7).
<br /> I). Indicate the tank capacity in gallans•'(ex.2S,f100 r>r LO,IJE)Ci etc.).
<br /> II. TANK CONI1:N15
<br /> A. 1. If MOTOR VI?L-IICLI3 1^"IJTI.,,check box 1 and complete items B & C.
<br /> 2. If not MO1'OI2 VLIIICI.,I. I'UF...I.,,check the appropriate box in section A and complete items B & I).
<br /> B. Check the appropriate bax.
<br /> C. Check the type of MOTOR VI�IiICL13 L'liTL(if.box:I. is checked in A).
<br /> I3. Print the chemical Warne of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Se.vice
<br /> number), if bax 1 is NO'T checked in A. ,
<br /> III. TANK CONSI72UC:'I7ON-MARK ONI'.I'1'I::M ONLY II+('t3iE)X A,B,C&c I)
<br /> 1. Check only ante itcnt 6n"1'YI'L;C)h SYS'TTM,TANK MA'i"TRIAL.., IN"TFI2LOIt LININC'r and Ct;)I2RE)SIE)N f'RO'I'};.C'I'ION.
<br /> 2. tf O"I'III�'R,print in the:space provided.
<br /> IV. PIPING INI�()RMA`ITON
<br /> 'I. Circle A if above ground;circle U if underground; and circle bath if applicab]e.
<br /> 2. If L,'NKNC)WN, cirr•Ie:; or if C71''IIh"K, print in space provided.
<br /> 3. Indicate the LIiAK I)Ld'TI:'.C''I"[C)N systcrn(s) used to carnply with the monitoring regoh•ement far the piping.
<br />��,
<br /> V. `TANK I.I�K DI?'I�.C'I10N
<br /> 1. Indicate the L,I::AK I)I:"I'TC';1'ION sy�stem(s} used ta'cam�lytvith the monitoring requirements far the tank.
<br /> VI. INI7E)RMA1"ION ON`TANK PERMANINII.Y CI,OSIr,I)IN PLAC:E3
<br /> I. FSITNIA"I"L;I) 1:).4'I'E I..AST L7SI�.D - MOtiI"II/1'IAR{7anuary, I9R8 or r1I/88).
<br /> 2. f�S'I'IMATF..,I:)E�L)ANl'I'I'Y of LIAZ,ARI)C:�US SUBSI"ANC:13 remaining in the tank(in Ciallans).
<br /> 3. WA.S`TANK TILI.,TI)W1`I"II Ii�IsItT MA'TI::;RIAL:� Check'Yes'or'NC)'.
<br /> APPI;ICAN'I"MUST'SIGN ANI)DA:I'E;7"I7II?I�Y)RM 11.5 INDICII`IT?I).
<br /> IN4'TRUE"I'ION I70It"I'III?I.00.AL AGI?NE:II?'�
<br /> The state undergrr>und strxrage tank identificatiari number is catnposed of the two digit county number, the three digit jurisdiction
<br /> number, the six dibit Cacility number and the six digik tank number, "The county and jurisdiction numbers are predetermined anr)
<br /> can be obtained by catking the State Boarik (}1ti)73'3-2121. "I"he facikkty number must be the same as�haw)i in form "A", "I"he
<br /> tank number map be assigned by the locale agency; however, this number must be nornerical anti cann<�t eantain an alphabet. If
<br /> fibs local agency prefers the State Board to assign tfte tank number,please leave it bla�tk_ ,
<br /> TT IS TIII3 RI3.SM)NSII3II,I`T'Y C)P'L'IIIx LOCAL ACiF.NCY'I'IIAT INSPI�,t'I'S"I'ICI:I;AC"II..TCY'I"'C)VI?RII�1''I7II;
<br /> ACCURAC.'Y OIx'I7II?INhE)RMA'1.'ION. 'I7IE L.00.AL,AGIzNCY IS RL�:SPE)NSI'I3I.I3 I7OR TIIE CE)MPL,I?"I'IE)N OF TIAs
<br /> "L,OC.AI,AC;I::;NCY USE ONL Y"INI'ORMAT'ION I3E>X ANI)I;C)R IRWARllING ONI?iK)KM"A"AND ASSOC.'IA'IT?i)
<br /> t*C)RM"I3"(s)'I'E)7�iE I?E)LLE)Y�IN('x ADI)I2E'S.'�
<br /> SCAIT E)It C.AI,IIzORNIA
<br /> ' SI`A'I1?WA'1'I:slt RIL'40URC1 S COI+TL'ROL BOARD
<br /> DATA PRCX�I'h�.SING CF.NI"ER
<br /> P.O.BE)X 52'T
<br /> PARAMOUNT',CA!)CI723
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