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IN91`RUCMONS FOR COMPLTUING FORM"II" <br /> GENERAL IN UI C) <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMrLS,PERMIT CHANGES, REMOVALS and/or any <br /> +g� <br /> other 8 INFORMATION CI ANG11 <br /> 2. This.form should be completed by either the PERMYr APPLICANT or the IDCAL AGENCY UJNDERGROU ND T'ANX <br /> 3, Please type or print clearly all requested information. <br /> 4. Use a hard plaint writing instrument,you are making 3 copies. <br /> TOP OF FORM.*MARK ONLY ONE ITINO <br /> 1. Mark an(X) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK Dt M1 P IION-COMPIFIM eA11.I'.I7F? -IF UNKNOWN-SO SPPCIFY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by theownerto identify the tarok(cx,AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MrG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. 'TANK CONTEXIS <br /> A. 1. If MOTOR VEHICLTi FUJI,check box 1 and complete items B cos C. <br /> 2.If not MC)'IOC VEHICLE:FUEL,check the appropriate box in section A and complete items 13&D. <br /> B. Check the appropriate box, <br /> C. Check the type of MOTOR VEHICLE FUEL L(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#, (Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> Lit. 'rANK CONIRRUCITON- MARK ONE rI .r . ONLY IN BOX A,11,C&D <br /> 1. Check only one item inTYPE OF SYS'IUM,'PANICT'E,'RIAL,INFERIOR RIOR LINING and CORROSION PROTT;C"1'lON. <br /> 2. If OTHER,print in the space provided. <br /> IV. <br /> PIPING INFORMATION <br /> 1, Circle A if above ground;circle UJ if underground,and circle both if applicable< <br /> 2. If UNKNOWN,circle, or if 0111ER,print in space provided. <br /> 3. Indicate the LEAK I}IiI;TC110N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE-1 ICDN <br /> 1. Indicate the LEAK DE'I'I CT°ICIN system(s)used to comply with:the monitoring requirements for the tank. <br /> . INFORMATION ON TANK PERMANEMI1..Y CIX)SED IN PI.AC;I? <br /> L ESTIMATED DATES LAS I'UTSE D-:O.N1`'T'II/YF AR(January, 1988 or 01/88), <br /> 2. ESTIMATED QUAINITTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITTI INE I'MATE RIAL?Check 'Yes'or'NO'. <br /> APP11CANT MUST SIGN AND DATE IIIE FORM NC A I. , <br /> INSTRUCTION FOR THE I.,AGENC'I.P—S <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 sho*n in form"A". 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 /> T IS 111ENS II: OF 371E IDC".AI>AGENCY'ITIAT SPEC°'I'S 11113 FAC;IIXI°Y TO VERIFY11113 <br /> ACCURACY OF 111E INFORMNITON. 11113 LOCAL AGECY IS RE—SPONSIBLE,MR171E C O PLUITON CII?TIIB <br /> "LOCAL AGENCY USI ONLY''INFOR ATTCIN BOX AND FOR FORWARDING O FORM QA"AND A SC)C LIVI7',IJ <br /> FORM'W(s)TO TI I?OUOWlNG ADDRESS. <br /> NI`I3 OFLIIt�C2RNIA <br /> 917 IV WATI.I.R RESOURCES C ONFROL BOARD <br /> C/O S.W.I:TFL P.S, <br /> DATA PROCESSINC34 CIM7ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA <br /> Ah1 <br /> r <br /> 1 <br />