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'INSI'RU ONS Ilii . 'INCE PORM'Ir <br /> GENERAL I.INT U 'IONS <br /> 1. One FORM"B"shall be completed for each tank for all NFW PFRW17,S PERMrr CII GES, EMOVAIS and/or any <br /> rather TANK INIURMATION CIIANGE. <br /> 2. This form should be completed by either the PERmrr ILLI r or the I,C)CAL AGENCY UNDERGROUND TAN <br /> SPH <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing,instrument,you are making,3 copies <br /> I'Op 017 FORM:IAMRK ONLY ONE 1`1711M" <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 DP ON-CO",,1'I: :e :;ALL..:? S-'IIx UN _SO SPFIMY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.AB7070). <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 10,000 etc.). s <br /> II. TANK CON113N`r!S <br /> A. 1, If MOTOR VF IIIC~I.:I: FUEL. check box I and complete items B&C. <br /> 2. If not MC1'E`OR 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 m(YrOR"t<EHIC;I..I^ f'L7EL(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 Service <br /> number),if box I is NOT checked in A. <br /> iff. TANK CONSTRUCTION-mARK ONE rrEm ONLY WX A,1f,C.&Tl <br /> 1. Check only one item in TYPE 0Fa S` SI'FM,TANK MATERIAL, LNI'ERIOR LINING said CORROSION EAROI"I M. ON.' <br /> 2. If OTHER,print in the space provided, <br /> IV PIPING A°ITON; <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable.' <br /> 2. If UNKNOWN,KNO i ,circle; or if C7TI-EFt,print in space provided.' <br /> 3. Indicate the LEAK DETECn0N system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DDI I°ION <br /> 1. Indicate the LEAK L7 ON system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INIU 'nON ONTANK 1'I?RMANI MMM C'I SED IN PLACE <br /> E <br /> 1. ESTIMKrED DATE IAS'I'USED-MON]IH/YI?.AI2(January,1988 or 01/88): <br /> 2. E 1)QUAI rIT['1'of IWARF3OUS SUBS-'ANC E remaining in the tank(in Gallons): <br /> 3. WAS'TANK FILLED WITII INEXI'M/VrERIAL2 Check'S'es'or'NO'. <br /> A$ I � I°SIGN AND RXIE`Dile FORM AS INDICKIIIJ. <br /> 9I7LCLIC7ITON FOR II?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 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 "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 /> I°T IS THE RESPONSIBIMY OFTHE t I ACI CY`THAT INSPI$IZFS THE VACaI °11IIi <br /> ACC U CY OP`T°IIE ENI I`ON. 'ITIE IX)CAL AGENCY IS RP—STONSIBLE FOR 111E CE7 .I.`ION OI-T11B <br /> *I L AGENCY USE PINI., IORMX- ON BOX AND FOR FORWARDING ONE VORM OA' `1113 <br /> FORM "(s)17011111 FOI.1,OWING ADD 3 S. <br /> SM171OF CA1.11tORNIA <br /> SIAM JV1'EIC RF—SOURCES CONMOL A <br /> /o Sm _ P. <br /> DXrA PROCINSING CENTIrR <br /> P.O.BOX 527 <br /> FARAMOUNF, <br />