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0 <br /> IN.WRU(71IONS FOR C()MPLLrI7NG FORM'B" <br /> GENERAL iNst'RucTIoNs, <br /> L One FORM "WsNflklhtco,npleted for each tank for all NFWPERA41`1S PERMIT CILANGM—, RI-I.MOVAI—S and/or any <br /> other T/,NK INFORMAIION CIIANG& <br /> 2. This fo,.)� would be completed by either the PERmrI'ArPLICAN`r or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPM.3'011. <br /> 3. Please type or print clearly all requested information. <br /> 4. 'Use 9 hard point writing instrument,you are-making 3 copies. <br /> TDP OF FORM,- 'M!� RK ONIX OMIT ITEM* <br /> 1. Mark an (K) in 11w box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the D or Facility name where the tank is installed. <br /> 1. TANK DFSCRIV11ON-(X)MPIMM4 ALI,'11711z%LS-W UNKNOWN-SCB SPEX3ff <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 MFG.). <br /> C. Indicate the year tile tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons 25,000 or 10,000 etc.). <br /> IL TANK CONI1s11.17S <br /> A. 1. If MOTOR VEHICLE M: EL,check box 1 and complete items B&C. <br /> 2.If not MOTOR VEHICLE 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 VEHICLE 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 Abstract Service <br /> number),if box I is NOT checked in A. <br /> III. TANK CONSTRUCIION-MARK ONE'rITM ONLY IN BOX A,K C&D <br /> L Check only one item in TYPE OFSYSFEN4,TANK MATFRIAL, INTERIOR LINING and CORROSION PROTECIION. <br /> 2. If 0111ER,print in the space provided. <br /> TV. PIPING INFORMADON <br /> 1. Circle A if above ground;circle U if underground: and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if 0111I R,print in space provided. <br /> 3. Indicate the LEAK DFIT"CHON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHI`EC`J1ON <br /> 1. Indicate the LEAK DEIECIION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMXIION ON TANK PHRMANEN`1`LY CLOSED IN PLACE <br /> 1. ESTIMATED DNI'E LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. E911MA'I'E13 QUANTrl'Y of HAZARDOUS SUBSIANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA11711113,FORM AS INDICA71110. <br /> INSTRUCIFION FOR111131 LOCAL AGENCII:—N <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. 'Ile 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 &)ard to assign the tank number,please leave it blank. <br /> IT IS'ITIE RES PONSIDUM OF'17113 LOCAL AGENCY*IIIAT INSTEC-fST1111 FACILITY TO VERH'YTI1E <br /> ACCURACY OFTIIE INIK)RMN]ION. 1110 LOCAL AGENCY IS RESPONSIBLE FOR TIIE,C(.)MPIYnON OFTIIE <br /> .IA)CAL AGENCY USE ONLY*INFORMXIION IX)X AND FOR FORWARDING ONE FORM W AND ASSOCIA11:113 <br /> MRM'B'(s)1`011113 FOLLOWING ADDRES& <br /> STWIT'OF CAI.111k)RNIA <br /> RRI—NOURCES(X)N-fROI.130ARD <br /> C/O W.W.I-A-11I.S. <br /> DATA PRO(MSSING CENTER <br /> 11,0- TIO X 527 <br /> PARAMOUNI7,(A 90M <br />