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*-4"WN, <br /> FOR COMPLIMNG FORN# -14- <br /> GENPRAL 1NS'IRU(711ON&- <br /> L One FORM "B"shall be completed for each tank for all NEW PFRMITS,PJ:,RMr1'C'lIANGF.S, REMOVAL-S and err any <br /> other TANK INFORMA11ON C[IANGF- <br /> 1 This form should be completed by either the PERMI'.I*M11111CANI'or the LOCAL AGENCY UNDERGROUNT)TANK, <br /> INSPEC7.1'OR- <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a hard point writing instrument, you are making 3 copies, <br /> 'MP OF FORM."MARK ONLY ONE rnim* <br /> 1. Mark-an (X) in the box next to The item that best describes the reason tire form is being completed. <br /> 2. Indicate the DBA clr Iacility name where the rank is installed. <br /> 1. 'TANK DESCRIVITON-COMPLFM ALL IMMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) # -If there is a tank number that is used by the owner to identify the tank(ex. A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMI.]TANK MF(3.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> 11, Indi;ate the tank capacity in gallons(ex.25,000 or 10,000 etc,), <br /> A. 1. If MOTOR VEHICLE FIA-11- check box 1 and complete items B& C. <br /> 2. If net MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items 13& D. <br /> "Qkaak the appropriate box, <br /> C. Check the type of MOTOR fLIT'ICLE!,MEL(if box I is checked in A). <br /> D. Print the chemical name of the hazardous sub,.�ancc stored in the tank and the CA,S4. (Chemical Abstract Service <br /> number), if box I is NOT checked in A. <br /> 111. TANK CONsIRUCITON-MARK ONE rIT.W ONLY IN I3OX A,D,C&D <br /> 1. Check only one item in TYPE OFSYS`I1HM1 ,TANK MA'IT.RIAL, INTF,'RIOR LINING and CORROSION PROTI.�'CIION. <br /> 2. It'01111-:T-print in the space provided. <br /> IV. PIPING INFORMIMON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,cin1c, or if 01-HER,print in space provided. <br /> 3. Indicate the LEAK DFTI'(7I'ION system(s) used to comply with the monitoring requirement for the piping' <br /> V. TANK IMAK DMIX:TION <br /> I. Indicate the LEAK DF,-MC`I I ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PIACE <br /> I. Dc�;HMAIT,'D DNITl IAS`I'USED-MOIN7I/YFAR(,January, 1.988 or 01/88). <br /> 2. 1:91'11%MITD QUAN1ITI'Y of HAZARDOUS SUBS-IANC1,remaining in the tank (in Gallons). <br /> 1 WAS TANK MIXED wrm INERT MATERIAL? Check Wes'or 'N6', <br /> APPIICANr MUS' Sl(.-,N ANT)DA'M-111P FORM AS INDICWITID, <br /> INS-1-RUC-1WI IT-1-1111 LOCA1,AGEN(119* <br /> The state underground storage tank identification number is composed of the two digit county number, the three digit 'ut;4sdiction <br /> 7 110 <br /> number, the six digit facility number and the six digit tank number. Ibe county and jurisdiction numbers are pred,14incd and <br /> A <br /> can be obtained by calling the State Board (916)739-242L The facility num!?i;r m, , T11c <br /> same as shown in form 'i <br /> tar 'fiffffiber may be assigned by the-wantgeffl-M-cr, this numOrr"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 /> 11'IS T11E RF-SPONSIBUXI"Y OF 111E LOCAL AGEWY111A17 INSPEC'I'S'111E FACIIXFY TO VEIR111f ME <br /> ACCURACY 01711111 INFOILMATION. 'I1IE'ee.00AI.ACwFNCY IS RE-SPONSIBI.M.FOR,nl-E COMPIJr11ON OF!1111; <br /> 'LOCAL AGI M.TY USI?ONLY'INFORMAnoNBOX AND FOR FORWARDING ONE FORM*A"ANDAW)CIN11.11) <br /> FORM'B'(s)1`0 11111 FOLLOWING ADDRESS. <br /> OF CA11FORNIA <br /> -!'NMWAj ' <br /> I)MA I�ROCIMIN(;CPN'll"R <br /> P-0.M)X 527 <br /> PARAMOUNT,CA 9X172.3 <br />