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INSIRUC CONS' OR C:OMPLEIING IFC) 'R»
<br /> GFNERAL INS UC C)NS
<br /> 1, One FORM "B"shall be completed for each tank for all NEW C`l»,Pl-lRmrr C'II111~GE , REMOVALS and/or any
<br /> other`t, NX INFX)RIVINPION iI GF
<br /> 2. is form should be completed by either the PEwwr APPIICANT or the LOCAL AGFNCYUNDER(IROUNDTANK
<br /> ,S11 ,£`IX)IL
<br /> 1 Please:type or print clearly all requested informati6n,
<br /> 4. Use a hard point writing instrument.,you are making 3 copies.
<br /> TOP OF IX)R ,-*MARK ONLY C)NE MIml
<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 17INw PPIC) -C:OMPLHIM All,rmms-IF uNKNOwN-SO SPECII74Y
<br /> A. Indicate owners tank Ii)#«If there is a tank number that is used by the owner to identify the tank(ex.AI370789).
<br /> Indicate the name of tltc.eomIlony,that manufactured the tank(ex,ACME TANK MFG),
<br /> C, Indicate; the year the tank was installed (ex, 1987).
<br /> I). Indicate the tank capacity in gallons (c)c.15,000 or 10,0W etc.).
<br /> IL TANK CONIIINI'S
<br /> Aa 1,If MOTOR VEHICLE I'UEI.,,check box'l and complete items B& C;,
<br /> 2,If not MO'.I'Olt VEHIC.t,I;FUHL,check the appropriate box in section A and complete:items B& D:
<br /> II.
<br /> Check the appropriate box.
<br /> C:. Check the type of MO';`OR V1.1-11C I I;FiUI T.(if box I is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the Cn.A.S. . (Chemical Abstract Service
<br /> number),if box 1 is NOT checked in A,
<br /> 111, TANK C ON51"RUC 1L)N-MARK ONE I"I`I: ONLY ,` ,B,Ca&T)
<br /> 1. Check only one item inTYPE OF sys,rI 1Vle'L"NK MyV173I IAL, INTERIOR LINING and CORROSION'P'12C)I Ef"I"ION.
<br /> 2. If OTHER,priest in the space provided.
<br /> IV, PIPING INIK)RMNnON
<br /> L Circle tl if above ground; circle U if underground; and circle both if applicable,
<br /> 2. If UNKNOWN,circle;; or of 0 MEA,print in space provided.
<br /> 3. Indicate the LEAK C)r;TE(NION system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK..I)I11`LICK)
<br /> 1. Indicate the I.F'AK I)ET C"110N system(s)used to comply with the monitoring requirements for the tank.
<br /> V1. INIZORMAIION ON TANK I'ItRMAN1 11,Y CLOS19)IN I°LACII
<br /> 1. K~5IIMAIMD DATE I.,;NST USED-MC7i Fll/YF',A 2 (January, 1998 or 0'1/88).
<br /> 2. ESTIMATED QUAN'11`1"1'of HAZ,ARIX)US SCJ13SI"ANC E remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED WFI'TT INERT MATT TCI.AL? Check'Yes'or:NL)'.
<br /> APPLI °I'musr SIGN AND 1)AiIII 7111:1 MRM AS INDIC'a11' t).
<br /> IN IJ£7.I1C)N R'L11 g 1A)C AL AGENCHiS
<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(91.6)739-2421. The facility number must be the came as shown in form "A' The
<br /> tank number may be assigned by the local agency; however, this number must benumerical and cannot contain an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank:
<br /> rr IS'I'IIEr RE-SPONSIBILrr OF'1`III;LOCAL GF.NC; °I°IIAT INSPEC:L 11111 F C 11:HY TO VERII `1TE
<br /> ACCURACY 0I117TE a ): '11014. 171E LOCAL AGENCY IS RESPONSM11.1 FOR 711111 COMPIE11ON OF 11111
<br /> 'LOCALCII?,N USE ONLY'I R,)RMA°I'ION )X N)FOR FORWARDING ONE IFC) *A7 AND ASSOCIATED
<br /> I ) -1r(s)110 31111 FOLL) NG1)I3 S.S.
<br /> STATE Oft C
<br /> A11FORNIA,
<br /> TSI' '?WAIMIR RESOURCES C ONI'ROL I30ARD
<br /> S. i:1k1LP.S, ,
<br /> DXrA PROCESSING CENTER
<br /> TER
<br /> P.00 X 527
<br /> PARAMOUN17,C'
<br />
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