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INSWRUCIIONS Wyk COMPLE'l'ING FORM*B'
<br /> GENERAL 1NS'PRUC1'lON9-
<br /> 1, One 1°C) 1I ".11"scull be completed for each tank for allNFEW PERMM,,P1; 1T`CIHANG,11% REMOVAIS and/or any
<br /> other TANK INFOitmYnON CHANGF?
<br /> 2, This form should be completed by either the P APPLICA N'l'or the IA)CAL AGENCY UNDERGROUND I 17ANK
<br /> INSPECIT)S.
<br /> 3, Please type or print clearly all requested information,
<br /> 4, Use a hard point-wTiting 1'astrument,Von are risking 3 copies,
<br /> 'MP OF I?ORNC-'MARK ONLY ONE, UMW
<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 /> I. TANK DYI-SCRWI70N-COMP1,11111 All,1`112AS-IF UNKNOWN-SO SPMI?Y
<br /> A. Indicate owners tank ID#-If there is a tank number that is used bythe owner to identify the tank(ex.AB70789).
<br /> 11, Indicate the name of the company that manufactured the tank(ex.ACME TASKK MFG).
<br /> C. Indicate the vear the tank was installed(ex. 1987).
<br /> 1). Indicate the tank capacity tel gallons(ex.25,OW or I0ff)0 etc.).
<br /> II. TANK CONIEMIN
<br /> A. 1If MOTOR V11110,11"FUEL,check box 1 and,complate items B &C.
<br /> 2, If hot MO'FOR,VI--1111CLE"FUEL,check the appropriate box in section A and complete items B &D.
<br /> 13. Clieck the appropriate box,
<br /> C, Check the type of MOTOR V1,'.IIICLE FUF'I.,(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 Abstract Service
<br /> number),if box 1 is NOT checked in A.
<br /> 111. TAN K CON'T.I'RUC'I30N-MARK ONE TIVIA ONLY 1N BOX A,11,C&1)
<br /> 1. Check only one its iftTYPE OFSySr C`1
<br /> -M,-M,TANK MAFERIAL,WIFERIOR LINING and CORROSION PR(:YI'L,CI'ION.
<br /> 2. If OTHER,print in the space provided,
<br /> iv. P1E*wc3 imsoRimiNnON
<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 LBAK DF.'IECTION system(s) used to comply with the monitoring requirement for the piping.
<br /> V. TANK 11�AK D113711"ClION
<br /> 1, Indicate the LEAK system(s) used to comply with the monitoring requirements for tile tank,
<br /> V1. INFORMA'17ION ONTANK PERMANN NITM CLAXSED IN PI
<br /> L DATF.i,LAS-17USED-MONTII/YEAR(January, 1988 or 01/88).
<br /> 2. ESTIMATED QUAN-PITY of IIA7ARDOUSS1 BSIANCE restraining in the tank(in Gallons).
<br /> 3. WASTANK FILLED WITH 1N14I<l'MAn.,,RIAL? Check'Yes'or'N0%
<br /> APPI.JCAN1.`MU,ST SIGN AND DA114,771E 1URM AS INDICATED,
<br /> INS'l[RUC170N FOR 7111i LOCAL AGENC 103
<br /> The state undenground storage tank identification number is composed of the mro 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. 4
<br /> Cl'IES 77-H!1U!%PONSIF11-X1Y Ir`1711E LOCAL AGE C3 T11K.1`1N,5PW-lf%, 11111 FRAC 1[XrY 10 VIIRH,'Y 711F,
<br /> ACCURACY 01VITIE IN17ORMA1,10N. ITIE LOCM,AGENC Y IS RI&SPONSHILE FOR 17.117 COMPI.I.qION OF11-1E
<br /> 'LOCAL AGF C"' USE ONLY'INFORMA110N BOX AND MR FORWARDINGi ONE FORM'A"AND ASSOCIATED
<br /> 1 1M'B'(s)TO`E`1113]FOLLOWING ADDRESS.
<br /> ,WAIE OF CATIFORNIA
<br /> ";I'A"
<br /> IE WAIMR RUSOURCFS CC) '1712)1K)ARD
<br /> ("'/()S.W.1u.1ps.
<br /> DXrA PROC14-SSING(1WIMR
<br /> P.O.BOX 527
<br /> PARAMOUNP,CA 90M
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