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INS'17RUCTIONS FOR COMPLLMNG FORM W <br /> GENERAL . U €) ®w <br /> 1. One FORM"B'shall be completed for each tank for all NEW PFRMr.M PERMIT CHANGES, I:7 C) A S and/or any <br /> other TANK I TI()N CHANGE <br /> 2. This farm should be completed by either the PERwr APPUCAN.r or the WCAI,ACA13NCY UNDERGROUND TANK <br /> INSPECrOR. <br /> k' 1 Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrunrent>you are making 3 copies. <br /> TC)P 017 X ONE I1I: <br /> 1. Mark an (X)in t e box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA`or I7acility name where the tank is installed. <br /> I, TANK DESCRIMON-COMPI17Mz AI I,M.WS O ::SO SPECIFY <br /> A. Indicate owners tank.Ill#-If there is a tank number that is used by the owner to identify the tank(ex.AI370789). <br /> B. Indicate the name of the company that manufactured the tank.(e)L A> E°TA.N MFG.): <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons-(ex.25,000 or 1Q,000 etc). <br /> 11. TA : <br /> A. 1.If MC)'IOR VEIIICI.E FUE1,,check box 1 and complete items I3&"C. <br /> 2.If not MOTOR VEHIC'IM FUEL,,check the appropriate box in section A and complete items B& D. <br /> B. Cheek the appropriate box. <br /> C. Cheek the type of MOTOR V IIIC1, FUEL(if box I is checked in A). <br /> D. 'Print the chemical name of the hazardous substance steered in the tank and the C.A.S. .(Chemical Abstract Service <br /> number);if box 1 is NOT checked in A. <br /> III. TANK CC) UC'IION ARK ow rrEm omy IN i3ox A,1I,;C& 13 <br /> 1. Check only one item in TYPE 0I�SXSIMM,TANk MATERIAL,IN71` ILIO)LINING and CORROSION PIZC)TEC`IION. <br /> 2. If OTII R,print in the space provided. <br /> 1"V. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground;and circle beth if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER, print in space provided. <br /> 3. Indicate the LEAK DSII ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IT-AK DETECTION <br /> 1 .Indicate the I; IC I7 C)N system(s)used to comply with the monitoring requirements for the tank. <br /> . INFORMATION ON TANK PERMANElf11,Y ffi:I SED IN PLACE <br /> 1. ESTIMATED DATE LAST USI I:)-MON`1 (January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANnTY of IIA7.AI2DOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WrrII INEWI`MA'TEIZIAI,?Check°ales°or'NO'. " <br /> APPLICANT °SIGN AND DWI'EI1111117 FORM AS INDIC. <br /> S U ON FOR771111 LOCAL.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 sir 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 pry". 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 /> rr IS TnE REsPoNsliEllury,of"IIID wcAL AGFNcY I IAT iNspEersnip, <br /> FAciury To irE1II17y'111I? <br /> ACCURACY OF 71111 INIIORMATION. "I II?I,C I.AGEN(N IS RESPONSIBLE FOR'11IE C;C) PI,II`I1ON O "ITIS <br /> OI L AGENCY USE CINI *IN17ORMNIION WX ANDFOR l ARI) G ONE ft W D A.S.° 1 3 <br /> FORM "(s)TO IIHI FOII,C) 'ING A3 III: S. <br /> rAW C)I7 SI?ORNIA <br /> rA1131 1t3 RE-SOURCES CONTROL BOARD <br /> DATA P ESSING :I:7 .`I <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9Q7M <br /> �x <br />