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IN91'RU('IIONS FOR COMPIVIING FORM"13- <br /> 0U.NERAL 1.NS`.I'RUC'11ONS-. <br /> 1. One FORM "B"shall be completed for each tank for all NFW PERMITS,PFRmr.r aiANcws, REMOVAUS and/or any <br /> other TANK INFORMATION(MANGE. <br /> 2. This fofm should be completed by either the PERM17FAPPLICANT or the I..(X:AL AGENCY UNDI.rROROUNDTANK <br /> 1N,%P1V,'FOR- <br /> 1 Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF 17ORM: *MARK ONLY ONE rI7EM' <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 DESCRIVIION-COMPHUM All. rEMS-IF UNKNOWN-SO SPFXM: 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(".ACME 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 /> 11, TANK COM17EMIS <br /> A. i. if MOTOR VEHICLE M: EL,check box I 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 VE111CLE 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.S4. (Chemical Abstract Service <br /> number), if box I is NOT checked in A. <br /> III. TANK cy-ws-TRumON-MARK ONE YffiM ONLY IN BOX A,B,C&D <br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTI`ERIOR IANING and CORROSION PROTECI'ION, <br /> 1 If OTTIF.R,print in the space provided, <br /> IV, PIPING INFORIVINHON <br /> 1, Circle A if above ground; circle U if underground, an(] circle both if applicable, <br /> 2, If UNKNOWN,circle; or if 0111EP,print in space provided. <br /> 1 Indicate the LEAK DF711"C'HONsystern(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK ITAK DI7 IX11ON <br /> i. Indicate the LEAK DE--l"ECRON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PERMAN—" , 1-3SED IN PLACE <br /> i. EsTmuvrul)DATE, LAST USED-MONTIT/YEAR(January, 1988 or 01/88). <br /> 2. ESTVv1A11,M QUANTFFY of HAZARDOUS SUBSTANCI.-l' remaining in the tank(in Gallons). <br /> 3. WAS'IANK FILLF.D WITH INEWI'MA'IT.7RIAL? Check 'Yes'or'NO'. <br /> APP11CAN-I'MUST SIGN AND DNI1,7111F K)RM AS INDICA71111). <br /> IN,171'R1JC`I'I0N FOR`I LOCAL AGENCTES <br /> The.state underground storage tank-identification number is composed of the two digit county number,the three digit jurisdiction <br /> number, the six di.-it facility number and the six digit tank number. The county and jurisdiction number,-,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 he 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 /> YFISVIES RUSPONSIBITSI"Y OF111E LOCAL AGENCY11INr INSPE(:IN171F,FACIUINV-)VFRIFY'1711H <br /> ACCUPLA(N OFTUR INFORMA170N, THE'LOCAL AGENCY IS RINPONSIBLE FOR17111 COMPLETION OF 1711i <br /> ILO CAL AGENCTY USE ONIA"INFORMIV17ON I1OX AND FOR FORWARDING ONE.FORM W AND ASSOCIXII:D <br /> FORM'B'(s)TOTHE.FOLLOWING AI'DRES& <br /> OF CALIFORNIA <br /> SPIVIT?WA`1TR RKSOURCMS CONTROL BOARD <br /> CIO S.W,KF—P.S. <br /> DNFA PROCESSING CC:flTER <br /> P.O.BOX 527 <br /> PARAMOUNf,CA WM <br />