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INS FRUMONSFORCOMP11,11 olk)RM'Ir
<br /> Cil.M'MALINS71'RUCITONS-
<br /> 1. One FORM'B"shall be completed for cwch tank for all NEW flf!Rm.,rr CHANGAIN, REMOVAI-13 and/or any
<br /> other'l.'ANK IMZORMA170,N CHANGE,
<br /> 2, This form should be completed by either, or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> 1 Please ty
<br /> ,pe or print clearly all requested :nffonnatjon,
<br /> 4. Use a hard point writing instrument,you are making 3 cqpies,
<br /> *MP'01?VORM."M
<br /> ,�k4K ONLY ONE rIT241
<br /> 1. Mark an (X)in the box next to the item that best describes the rea=son the form is being completed.
<br /> 2. Indicate the D or I'acifity name where the tank is installcd.
<br /> I. TANK DESTON-COMP1,911i AII,r1liMS-IF UNKNOWN-ISO SPE41kry
<br /> A. Indicate owners, tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.A]370789).
<br /> B, Indicate the name of the company that n'kinufactured the Tank(€x,ACME TANK MI"G.).
<br /> C. Indicate the year the tank was installed (ex, 1987).
<br /> D, Indicate the tank capacity in gallons (ex, r5,(ff,or 10,0(){)ctc.).
<br /> 11. TANK COI I'ENI
<br /> A. 1. If MO'],'(.)R VEHIC111,FUEL, check box I and complete items B& C.
<br /> 2. If not MOTOR VEFIICI,I",' F'UEI,,check the appropriatc box in section A and complete fterts B& D.
<br /> M Check the appropriate box.
<br /> C. Check the type of marOR VEMICLE 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,#. (Cherincal Abstract Service
<br /> number),if box I is NOT checked in A.
<br /> 111, TANK CON,1;I'RUC11ON-MARK ONE 1"1'M,1M ONLY IN BO,X A,B,C&D
<br /> L Check only one item in'I 017 SYS'I'EM,TANK MNITRIAL,INTERTOIR LINING and CORROSION PROTEC110N.
<br /> I If 0`1711ER,print in the space provided.
<br /> IV. PIPING INPORMNITON
<br /> 1. Circle A it above ground; circle U if underground; and circle both if applicable,
<br /> 2. If UNKNOWN, circle;,or if OTHER,print in space provided,
<br /> 3. Indicate the LEAK DE-111010N system(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DDI` C11ON
<br /> 1, Indicate the LFA K DT3'I`l.1CI'l0N system(s) used to comply with the monitoring requirements for the tank.
<br /> VI. INIURMNIION ON°I" PEIRMANI NI LY C10SED IN PLACE
<br /> 1. I3S`nMAJT.D DA11 iAsi,uam-mowivylj-AR(January, 1988 or 01/88),
<br /> 2. F—s-rummum QUA.�rrrry c)€HAZARDOUS'SUBST'ANCE remaining,in the tank(in Gallons).
<br /> 3. WAS TANK-ILII LED WITH INMU'MATERIAL? Check 'Yes'or'NO'.
<br /> AppijcAm,muss SIGN AM DNIL711111,lk)RM AS INDI(WIED,
<br /> INS rRUC110N 1URT111i IX)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 must be the same as shown in form "A". 'Ibe
<br /> tank number may be assigned by the local agency; however, this nurn6cr must be numerical and cannot contain in alphabet. If
<br /> the local agency prefer-,the State lk,)atd to assign the tank number,please leave it blank,
<br /> TI'IS'nfli R&SPONSIBUXIT OF 111E LOCAL I?ACIL]r[*Y'1'0 VER11"y 111E
<br /> ACCURACY 01411111 JNFORMKIION. 'ITIET LO(Al.AGENCY IS RWISPONSIB1,13 FOR'llffIx COMPHTLV ON OF 711134
<br /> *I 1..AGPNCY USTI ONLY"INFORMNITON BOX AND FOR EORWARDING ONB FORM'A"AND ASSOCINI`HD
<br /> MRM 'B'(s)TO-1.1111 FOIJ,0WTNG ADDRE&S.
<br /> 9l 113 OF CA11FORNIA
<br /> .11WILT WNIER REW)URCES CY)NTROL IX.)ARD
<br /> C/o'&W.Ila P.S.
<br /> DATA PRO GIi"SING CEN17ER
<br /> P.O.BOX 127
<br /> PARAMOUNI',CA 90M
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