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INS'L.RUCIIONS a Or. t OMPIJ I'J` G FORM'I.3' <br /> OffNE.RAL IN5.1.7ZUC:I ION& <br /> L One FORM"B"shall be completed for each tank for all NEW PERMI I.,PERMIT C7•IANGFS, PtEMOVAI S and/or any <br /> other TANK:INFORMA'170N CIIANGE. <br /> 2. °I:'his form should be completed by either the PERWI'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPWI'OI2, <br /> 3. Please type or print clearly all requested information, <br /> 4. Use a hawd.point writing instrument,you.are making`3 copies.` <br /> TOP OF FORM;'MARK ONLY ONE ' <br /> 1. Mark an (X)in the box next to the item that best describes the reason the fora is being completed, <br /> 2. Indicate: the DBA or Facility name where the tank is installed, <br /> I. 'TANK DrSCRIPI7ON-C OMPI U �i ALL r.1VIW9-IF UNKNOWN-SO SPECM?Y <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> I). Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> IT. TANK CONI7ENI'S <br /> A. 1. If MO'T'OR VEIIICLF FL113L,check box I and complete items B&C. <br /> 2.If not MO`I'L,?R VEHICLE FUIT,check the appropriate box in section A and complete items B 8c 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 NOTchecked in A. <br /> III. TANK C()NS1'RLIC 170N-MARK.ONE rI"IM ONLY IN BOX A, I3,C&D <br /> 1. Check only one item in 'TYPE OF SYST FNl,TANK MA'FERIAL,INTI RIOR LINING and CORROSION PRO'ITC`PION <br /> 2. If CI'I'11FR,print in The space provided. <br /> IV. PIPING.INF RMNHON <br /> L Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If IJINK OWNT,circle; or if 0'111tiR„print in space provided. <br /> 3, Indicate the LEAK DF I"T3CHON systems) used to comply with the monitoring requirement for the piping. <br /> V. TAMC I.I4AK,DFI1X,'PI0N <br /> 1. Indicate the LF,AK DEFFC=1100 systems) used to comply with the monitoring requirements forthetank. <br /> VI. INFORMA'T'ION ON TANK PERMANEI BIN C'I1C3SED IN PJ ACNE <br /> I. ESI'IMA"IBI)DArr, LAST IJSI D-MONMI/YEAR(January, 1988 or 01./88). <br /> 2. FS11MA'T'I3I)OUANFITY of HAZARDOUS SUBS`I:'ANCIE remaining in the tank(in Gallons). <br /> 3. WAS'IANK F'ILLI>I) WITH INEWr MA`I"1 L7 Check 'Yes'or'NO'. <br /> APPLICANT MUST'SIGN AND DA,;I'E'I7W.FORM AS INDICNIT31 <br /> INLST'RUCI7ON FOIL THE LOCAL AGENCIES <br /> t tic state undcrground sto ral c 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 /> be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form'A". The <br /> numbcr may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br /> locai agency prefers the State Tsoard to assign the tank number,please leave it blank. -- <br /> IS TIE R SI ONSIBILrIY 01711I13 LOCAL AGENCY'I I1AT INSPf WTS B'IIE FACTLI'I"Y TO VERITY 1I171 <br /> A(X'UI AC Y OF1711i INFORMN110N. `I II:1E LOCAL AGENCY Y IS RFSPONSIBLE'FOR TIIE COMPIT'I`ION OF TI1E <br /> 1110CAL AGENCY USE ONLY'IIT€RMIVI"ION'IBOX AND FCIR FORWARDING ONE FORM'A'AND A,%OC 1X.1`ED <br /> t ,)RM'11'(s)O`OTE I IA OWING ADDRE S, <br /> "RWI'E CTIA C.AIJFORNIfti. <br /> 151'd1I'E WNFER RESC)IIRC KS CO I`ROL BOARD <br /> DATA PROCIMING CEi I'ER <br /> P.0) 13OX 527 <br /> PARAMOUN17,CA 3 <br />