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TN's['RU(711ONS Ik)R COMPI-JUING FORM'IV
<br /> GENERAL INS`IRUCnONS:
<br /> 1. One I'ORM "B"shall be completed for each tank-.for all NEW PERWIN,PURMT.1'CLIANGHS, RE'MOVAISind/or ang
<br /> other TANK INFORMATION CHANGE,
<br /> 2. 'I'llis form should be completed by either the PERMI'I'APPLICAN17 or the LOCAL AGENCY UNDERGROUNDTANK
<br /> INSPIVI'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 rll:N*
<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 /> 1. TANK DF-SCRIP`170N-COMI111-111i All.171EMS-IF UNKNOWN-SO SPECIFY
<br /> A. Indicate owners tank 11) # If there is a tank number that is used by the o%iier to identify the tank(ex. A1370789).
<br /> 4'
<br /> B. Indicate the name of the company that manufactured the tank(ex.AC\41...,rANK mrici.).
<br /> C. Indicate the year the tank was installed(ex. 1987).
<br /> 1). Indicate the tank capacity in gallons(CK.T5,(XX)or 1.0,000 etc.).
<br /> 11. 17ANK(X)NIVIVES
<br /> A, 1. If IM101'OR VEHICLE FUI-1., check box 1 and complete items B&
<br /> 2.If. not MOTOR VEHICLE FUE.I.,, check the appropriate box in section A and complete items 1.3 & D.
<br /> 13. Check the appropriate box.
<br /> C. Check the type of MOTOR VEHICLE FUT-1.,(if box I is checked in A).
<br /> 1). 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 /> 111. TANK CONS-IRUC7110N-MARK ONE 1711W ONLY IN BOX A,B,C&D
<br /> L Check only one item in TYPE OF SYSTEM,TANK MMATERIAL, I.NTERIOR FINING and CORROSION FROTEX7110N.
<br /> 2. If OTIIER,print in the space provided,
<br /> IV. PIPING INFORMA717ON
<br /> 1. Circle A if 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 DFTEC`IT0N system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK LEAK DLr`BCnON
<br /> 1. Indicate the LEAK DFAT"('11ON system(s) used to comply wraith the monitoring requirements for the tank,
<br /> VL INFORMATION ON TANK PE.RMANENIT.Y C1.OSITD IN PJACE
<br /> i. PSrimmil'I) j.Asr USED-l1O.N`I1I/YI'-AR(January, 1.988 or 01/88).
<br /> 2. EFI'IMA-IZ 0UAN`ITFY of IIA7ARDOUS SUB,51'Y\NCE remaining in the tank(in Gallons).
<br /> 1 WAS TANK F111,H)wriii INFRT%,1A'1 I F'RIAL? Check Wes'or'NO'.
<br /> APPIICANF MUST SIGN AND D/VFLI'ITIE FORM AS INDI(W1`ED,
<br /> INS-IRUCITON FOR7111i 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 six digit tank number. The he 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 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 /> rl'ISIIIERISPON,SIBII,TI'YOI"111EI,OCAI.AGI.N('Y'IIIATINSPI.X.'I'SnIE17A(,'Il,rl'YIX)Vl, IIE
<br /> XI-f'n
<br /> ACCURACY OF'111E INFORMATION. '17111 7-OCAL AGENCY IS RESPONSIBIT FOR 171F COMPLE-NION OF11IF
<br /> "LOCAL AGINC-Y USE ONLY*INFORMA7110N WX AND FOR FORWARDING ONE FORM "A'AND ASSOCIN[TA)
<br /> FORM'B'(s)TO 7111 FOLLOWING ADDRE&S
<br /> SIWJT's OF C-AI.IFORNIA
<br /> WA'AIR RESOURffN COM'ROT,BOART)
<br /> �"'/01 5.w'11'-fU11`-11'1,
<br /> 1,)/VkA PROCESSING CENIT'R
<br /> 1'.O_IX)X 527
<br /> PARAMOUNT,CA%M3
<br />
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