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z. 7 7 <br /> 77 <br /> INST RUCIIONS 17OR COMPIFIV FORM*Ir <br /> GENERAL IN,1;1`RUC`i1ONS-. <br /> I. One FORM"B"shall be completed for each tank for all NEW PF"RMT[IS,PERMIT CIIANGES, RUMOVAI-Sand/or any <br /> other TANK INFORMATION CIIANGR <br /> 2. This form should be completed by either'Ihc PERMIT'APPLICANT'or the 1,OCAI,AGLNCY UNDERGROUND TANK <br /> -INSPEC.170R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies, <br /> '11OP OF FORM: *MARK ONLY ONE rnaw <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 whcre the tank is installed. <br /> I. TANK DESCRIPTION-CX)MPIH1*E ALI,1`11HMS-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.ACNIE 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.). <br /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEIIICI11 F11.11,check box 1 and complete:items B &C. <br /> 2. If not MOTOR VFIIJCIAE 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 vr-,l`IICIX1 FUEL,(if box 1.is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstrao,Scn.,icc <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSFRUC110N-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYS'T'EM,TANK MATERIAL, INTERIOR LINING and CORROSION PRO"113C]'JON. <br /> 2. If OTIIEI,',,print in the space provided. <br /> FV. 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 OTHER,print in space provided. <br /> 3. Indicate the II3AK DI.nT'CI'ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVIE(711ON <br /> 1. Indicate the I,EAK DEIT.C11ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMNIION ONTANK PERMANI.W11M CIA)SEID IN PLACE <br /> 1. ESTIMA'17D DAIF"LAST'USED-moNTn/YL.AR(January, 1988or01/8.8.). <br /> 2. EsTmATED QuAyrriy of HAVARDOUS SUBSI'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK•FIILED WITH INT:1;(f`,MXI1.4,,R1AI..? Check 'Yes'or'NO'. <br /> APPLICANT MUST SK3N AND DA111 3111.11 FORM AS INDICATED. <br /> INS'IRUC17ON FOR 3111?IA)CAI,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 /> PI'][S'11111 RESPONSIBIE111"Y OF 111E IX)CAI.AGENCY 111ATINSPIX373 77113 FAC11XI"Y TO VERIVY'171E <br /> ACCURACY 01711113,INFORMATION. 'nIE IA)CAI,AGENCY IS RESPONSIBIE FOR 111E COMPIITIION OF*111E <br /> *1,OCAL AGENCY USE ONLY*INFORMN17ION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM-13-(s)TO'11113 14011,0WING ADDRESS. <br /> SrA7111 OF CALIFORNIA <br /> STAIE WATER RESOURCES CONI'ROI,BOARD <br /> CIO S.WX-F-P.S. <br /> DATA PROCESSING CENFER <br /> P.O.I)OX 527 <br /> PARAMOUNI7,CA 90723 <br />