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INS-rRU(71IONS FOR COMPLI-?IING VORM"TV <br /> GENERAL wsmucnow <br /> 1. One T;OWM W shall be completed for each tank for all NEW PERMIT'S,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANG11- <br /> 2. This form should be completed by either the PERMIT APPLICAW or the LOCAL AGI.WCY UNDERGROUND TANK <br /> INSPTLCIX)\L <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM; "MARK ONLY ONE ITEM* <br /> L Mark an (X)in the box DCXt 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 DESCRIPTION-COMPLETE All,rIEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 1.0,000 etc.).' <br /> IL TANK CONIENn' <br /> A. 1. If MOTOR VEHICLE;FUEL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VE11ICTS'.FUFIL(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.#. (Chemical Abstract Serv;ce <br /> number), if box i is NOT checked in A. <br /> III. TANK CONSMUCnON-MARK ONE ITEW ONLY IN BOX A,A C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided, <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle: or if OTJIER,print in space provided. <br /> 3. Indicate the LEAK Dt'JEC-110N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETITE]ION <br /> 1. Indicate the LEAK DHT',CI'ION system(s) used to comply with the monitorring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANf WIlLY CTA')SFD IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTFI/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTFIN of HAZARDOUS SUIISTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITI I INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE TIIE FORM AS INDICATED, <br /> INSTRUCTION FORTIJE LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction t. <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 (91(;)739-2421. The facility number must be the same as shown in form W. 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 /> ri,IS'nIE RESPONSIB11.11'Y 01111112 LOCAL AGENCY THAT INSPECIN*171113 FACEIM TO VERIFY THE <br /> ACCURACY OF ITIE INFORMATION. '171E LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF 171B <br /> *LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM-W(s)TO 17111 FOIl..OWING ADDRESS. <br /> SrXIM OF CALIFORNIA <br /> SfA'n*l WATER RESOURCES CONTROL BOARD <br /> C/o S.W.Rn P.S. <br /> DATA PROCESSING CMW17ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />