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GENERAL L I `I°RU01 yNS.
<br /> a, One FORM "B"shall be completed for each tank for all NEW PERM17FS, PIA M rr CHANGES, EMO I.S and/or any
<br /> other TANK I.NIk.)RMA11ON CILANGPI
<br /> 2, This form should be completed by either the PERMrl'APPUCANT or the LO(AI,AGItNCY t1NI ERGROUN3 BANK
<br /> pP;P "C`rOP-
<br /> Please type or print clearlyall requested information,
<br /> 4, Use a hard point writing instrument,Vests are making 3 cojncs.
<br /> 'J'OP OF FORM: 'MARK ONLY r1VM1
<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 Gracility name where the tank is installed,
<br /> 1. TANK Iii-SCMR.IVI'ION-COMPLUMf All,IT14 S-IIr UNKNOWN«SO SI M31rY
<br /> A, Indicate owners tank ITS #-If there is a tangy number that is used by the owner to identify the tank(ex.AI370780),
<br /> B. Indicate the name of the company that manufactured the tank(ex,ACM A°I ANK MFG.).
<br /> C. Indicate the year the tank was installed(ex. 1987).
<br /> I). Indicate the tank capacity in gallons(ex.25,€0 0 or 10,(M etc.).
<br /> 11. TANK C;ONI'EMIN
<br /> A. I, If MOTOR VEHICLE,FUEL,check boa I and complete items B x C,
<br /> 2..If not MOTOR VE111C 1 FUEL,check the appropriate box in section A and complete items II&I).
<br /> B. Check the appropriate box,
<br /> C. Check the type of 1viC?"I"("8I2 VEHICLE HIC LE IT, 11- ,(if box"1 is checked in A).
<br /> D. Print the chemical name of the hazardous substance steered in the tank and the C.A.S. ,(Chemical abstract Service
<br /> number),if box 1 is NOTchecked in A.
<br /> III. TANK C~OI RUC`I1ON-MARK CLIVI:171EM ONLY IN BOX,A,13,C ffi&D
<br /> 1. "Check only one item in"I Y'tz1;CIF S�SII;IiI,'IA�IC A'II T I. I.,Ilv;f`E;RIOR LINING and CORROSION PRO E'0'1 N
<br /> 2, If 01TIE ,print in the,space provided.
<br /> IV. PII'INCIINIX)RMATION
<br /> 1. Circle A if above ground,circle 3 if underground,and circle both if applicable,
<br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided,
<br /> 1 Indicate.the LLAK DiETE'sC11ON system(s)used to comply with the monitoring requirement for the piping
<br /> V. `[A K I,I K DffpfXTJ10N
<br /> 1. Indicate the LEAK I)EI'E(TiCIN system(s) used to comply with the monitoring requirements for the tank:
<br /> VI. INFORMATION ONTANK,I ERMI 1N E,N'I`M CLOSICI)IN PI CI1
<br /> 1. 051T'4/101-11)LFE€,Ali1:'USED-MONTI'tIJ FAR (January, 1088 or 01/88).
<br /> 2. EffrIMA'I ED QUAN.rrFY of HAZARDOUS SUBS'I"ANCI.', remaining;in the tank(in Giallons).
<br /> 3. WASTANK I=II LEE WWII INE1Zl': 1E,,RIAL?Check'Yes'or'NO',
<br /> AI PLP b Nr MU5FSIGN AND ISA"IE`I'II1 IURM AS INDICATED,
<br /> IN, UC110N;I R T1 IF LO(AL AGFNCIES
<br /> The state underground storage lack 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 comity and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State Board (916)73e3-2421. The facility number must be the sante as shown in form "A". 'i'§te
<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 StateBoard to assign the tank number,please leave it blank.
<br /> r1"Is i7m.RFsP0NSlBI1.nY 01711,113 LOCALAGENCY TIIX1'INSPE(7I`S'I111i FAC11M TO VEIRIFY 114E
<br /> ACCURACY WI"I Is 11dFORMNITOM '11111 LOCAL AGHNCIY IS R0SPONSIIILH FOR 111E CCD IX-11 N 017 111r,
<br /> 'I C I AGI4 C`Y USi ONLY'IN RMA`l O AND FOR FORWARDING ONE FO 'A'AND, SSOCIA711113
<br /> FORM-13-(s)T01111.41 F()IJ,0WING ' Ik3 E&S.
<br /> STA71T,OF CA11FORNIA
<br /> DA.TA PRO(NiSSING C ° PI> .
<br /> P.O.BOX 527
<br /> If t3UNICA 90M
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