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YNSt RUC711O S FOR(X)MPLUITNG FORM'Fr
<br /> CSIt. I*:ICsi,'III2C�I If) S:
<br /> i, One FORM RM"B"shall Inc.completed for each tank for all NEW PE S,PERM `C'II NGTI , PJlMOVAT,S and/or tmv
<br /> otlret'T, K INFORNIX110N C HANGT
<br /> 2. This form should be completed by cither thePE KmI' P1T1(ANF or the;1,0(7d,a (;ENC 'PX( 1)I:;22CiIC 3I.Thdi)'I"Atm
<br /> INSPECTOR:
<br /> 1 Peas ,yl c car print clearly tl requested information.
<br /> L. Use a hard point wi frog instn dv wnt,youi arca rnaknng 3 copies_� �
<br /> TOP OF f,"Olslef 'MARK ONLY ONE TIT'SP
<br /> ?'hack an, (X)in the ,ox ""A 1cl the hens that i csi describes the reason the form is being completed,
<br /> a Irz,i anic the DBA or Vkwility came w= cre the tank is installed, ..i
<br /> I. 'IANK'IANI)I,SC;III I10N-t'D I'I„In'Ll ALL ri'I? S v I a UNKNOWN«`0 S 14
<br /> Alnd"caoa owners tank I _If there if a,tank number that is used by the owner to identify the tank(ex.A)370789).
<br /> I3. Indicate the name of the company that manufactured the tank(ex,f4C?vfl TANK 1"CL),
<br /> C. Indicate the year the trick was installed (ex. 1e}87).
<br /> I'9, Indicate the tank capacity in gallons (ex.25,000 or 10,(M etc.).
<br /> Ii. TANK C C),I IV I S
<br /> A, If MOTOR VEHICLF"FUTL,check box 1 and complete items B& C,
<br /> 2- a n,>t MOTOR VEHICLE,FUF', ,check the appropriate box in section A and complete ite:m.4,B &I),
<br /> B, Check the appropriate box.
<br /> Cl I-heck the type,of�I TOR I'SIIIC'Ll",11,11-T(if box 1 is checked in A).
<br /> Il, Pont ting;chemical name of the hazardous substance stored in the tank and the C'.A,S. . (Chemical Ahstraacp Service
<br /> tumbe,r),if box 1 is Ni'T checked in A,
<br /> III "TANK C'OItdS-MMC 110 -MARK ONE rITIM ONLY IN BOX A,II,C;&D
<br /> L Check ck only one itern in'1"a'PEI t)1'SYf,'1"II ,"I'ANK MA 3`kIRIAL IN I'I:'' IO 1ANING and CORROSION I'I2,t")'I"fi("I"ION,
<br /> 2, It C>>°i sIIiP,Isr€sat in thc, sp<acc, g},-=i"icled,
<br /> IVB 111111G IITDR ICP
<br /> 1, Circle A of a ove ground;circle'U if unde:rgrounde and circle bath if applicable.
<br /> 2, If UNKNOWN,circle; or if Ea`i`HL"R,print in space provided,
<br /> :I. Indicate the 1.tAK used to.comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DIII I:"I'IC)Td
<br /> 1, Indicate the LEAK DEF F,,('I'10N system(s) used to comply with the monitoring requirements for the;tank,
<br /> I. INFORMXITON ONTANK PERMANEMILY CLOSED IN PLACE
<br /> L I:IStlM}T1,7'I)FIXIT,"LAST USI )-MN-PT/-1'F-AR.(Ifanu ry, 171%or 01fI38).
<br /> 2, Eq1 1< Tf,,IIa C.?UrrNN"I lY of IIALIdI OUS SCii1151'.ANC E remaining in the tank(in Gallons).
<br /> 3, WASTAINK FILL 1,I)WITH INERT A"I'I RIAL" Check'Yes'or'NO'.
<br /> i'I'I:.IC"t?s t'MUST SIGN AND DWII?17W FORM AS IND1 III),
<br /> NS17JUX—ITON FOR71113 LOCAL AGENCTIlS
<br /> I i=e state underground storage tank identification number Is ccri Ix)sed of the two digit county number,the three digit jurisdiction
<br /> arMe'Mr, ft six emit facility number and the six digit tanknumber. The county and jurisdiction numbers are predetermined and
<br /> ,,a be by c a`li`tS,he sl alt,Board (916)719-2421, The facility number must be the same as shown in fa rrn 'A'. The
<br /> ua,.k n a,i 1le' rraay be any the h,)cal arc r,Eyr hlvvevcr,this number must be numerical and cannot contain an alphabet, It
<br /> a., uncal agencyie;'e.,l,the state board t.t a q,;n the tank naambcr,please leave it blank.
<br /> CI°IS"I'I11"s IIIISm*iISII,fu,n y c:IF THII LOCAL C1IsI C f "II I°I I'IIC IS i3ii?PA(' r,['°§TO V13RUT'1IF
<br /> t,.C..I It C C)I;,`I IiII Ii I t)IC "I"ICt 'I" lls I.0 C AI, (3l,, 3C I'i I f,'SPO SSII.111 I `:IIIF CC7 I't,I:I`IO Off°Kilt
<br /> I<tIC L A(AfalC'r` Lgilf ONLY' NI?(,)RM/ I;ION IIC)K AND 177 M� RWA DI G ONE FO *V ANIS SSOCIA'I 'D
<br /> FORM, 'lr(s) 1143 FOLLOWING. DDRIISSs -
<br /> S`11! 'ER M I..IR(IlS C'ONFRC)I,BOARD
<br /> C'myyj((C)gg rqq. a��Ilg ps-'P's CIbiSING gg pp gb,ME
<br /> fa. .13O%u5 za a' `-
<br /> PARAI7I,CA 90 �3
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