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-rv�+�r: r ��,,y„"':C -, .vk^' .. c„ .„?a.'�. war•^. y, p-n ui a. w .a,. r :w.M n. .. 4 x _ w.:. <br /> INSTICIIC`1TC)NS FOR COMPLU17ING FORM"B” <br /> GENERAL IN, U C) <br /> I. One DORM "I3”shall be completed for each tank for all NEW PERMITs,PERMIT`C:1 CII:>19, REMOVALS and/or any <br /> other TANK INFORMAITON CIIANC113. <br /> I This form should be completed by either the PERMYr APPLICANr or the IDCAL AGENCY UNDERGROUND TANK <br /> 'P 17011. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are snaking 3 copies. <br /> P OF IORM:*MARK ONLY ONE °IW " <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 IDIA 1 ON PI.,i'1"13All,1711M-IF UNKNOWN-So SPP ?y <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.ACME;TANK 1VII'(.i.), <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 /> 11, TANK C,O I'13NI <br /> A. 1.. If MOTOR V1.71110.17 FUEL,check box I and complete items I3&C. <br /> 2. If not MOTOR VEHICLE LES F'U L,check the appropriate box in section A and complete Items E3&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). <br /> 11 Print the chemical name of the hazardous substance stored in the tank and the C.A.S. . (Chemical Abstract Servide <br /> number),if box 1.is NOT checked in A. <br /> III. TANK CC)Ns UCITt)N-MARK ONE rI`EM ONLY IN );X A,13,C;&L) <br /> 1: Check only one item in TYPE 01'SY SI E'![,TANK MATERIAL,IN'I'ERIC)IL LINING and CORROSION PROTEC"110N. <br /> 2. If C)°I'I-IEA.print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 1 If UNKNOWN,circle; or if OTEIE3IZ,print in space provided. <br /> 3. Indicate the LEAK I)I::IECI'IC):N system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE INMON <br /> 1. Indicate the LEAK I)i;I13C 1`ION system(s)used to comply with the monitoring requirements for the tank. <br /> . INFORMA11ON ONTANK P13RA n CLOS IN PIAC1? <br /> 1. 1,57 711 3AT7 I)DATE LASTUSED-M6:tNTII/Y I2(January,1988. or 01/88). <br /> 2. ESTIMATED QUANI'IT"Y of IIAZAIWOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WASTANK FILLED WrIll INE I'MATE RIAL?Check'Yes'or'NO'. <br /> APPLICANI'MU1917 SIGN AND DATETTIE,I7() )IC:A710. <br /> w `(IC,11C)N I 1Z If;LOCAL AGENCIES <br /> S <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 hoard (936)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 /> iT isum REspoNmn=o nfn LocAL,ACII C."Y t1I yr IIdspEct's°1 m FAC;II T'1 Y 170 vERIFY711E ' <br /> ACCURACY C)1;"111I?I '11C)N. THE LOCAL AGENCY IS RESPONSIBLE FOR 11M CC) PLI ITC)N Of'1II13, <br /> «I s AGENCY L SI1 ONLY*INFORMNnON BOX AND MR 17ORWARDING ONP f "A" I3 ASSO( •IIN) <br /> I?C) "13°(s)TO IVE FOLLOWING ADD <br /> s'IWI1r 017 CA11PORNIA <br /> SI'A°1'I? A°I.1I RESOURC05 C ON'I`IZC)I..BOARD <br /> C;/C)S. .I. I,_P s» <br /> DATA PROCESSING CI r <br /> P.O.BOX X 527 <br /> PARAMOUNI7,CA <br />