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1 SI'RUC.`110 S IX)R COMPLINING FORM RB" <br /> GENERAL INSPRUCDONS- <br /> L One FORM "B'sball be completed for each tank for all NEW PERMITS,PE? I°I'(1LKNORS, RE MOVAI.S and/or any <br /> other TANK, X) ATION CILANGE <br /> 2, 't`his comm should be completed by either the 1'ERNI"' PI,C°.ANI'or the 11)GAL AGENCY UNDERGROUND'I'ANK <br /> I SP _ "1`OR. <br /> . please type or;print clearly all requested information. <br /> 4, Use a hard Tx)mt writing insTrumem,you are snaking 3 copies. <br /> TOP OF 1 " AA"MAAK ONLY oNF i'i'I?w <br /> 1. Roark an (X)in the box next to the item that best describes the reason the form is being completed, <br /> 2. Indicate; the DDA or Facility name where the tank is installed. <br /> I. TAN DFS .R t1C) -CAOMPLE111 All,ITEMS-IF UNKNOWN_SO SPECWY <br /> A. Indicate owners tank II) #-If there is a tank number that is used by the owner to identify°the tank(ex. AB707,19). <br /> B. Indicate the name of the company that manufactured the tank.(ex.AC:MF.. TA IC MEGs). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> I). Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.). <br /> H. TANK CONrLWI <br /> A. 1. If MOTOR VEMICLE FUTEL,check box 1 and complete items B &C. <br /> 2. If not MOTOR VEHICLE DUEL,check the appropriate box in section A and complete items B&I:). <br /> EJ. Check the appropriate box. <br /> C. Check the type of MOTOR VEMICLE FUEL(if boa 1. is checked in A). <br /> D. Print the chemical narne 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. TANK CC? ,13UC 11C) -MARK ONE n-FM ONLY IN BOX A,B,C&E) <br /> 1.. Check only one item in TYPE OF SYSI°F ,°1r1�FC RRA'"IEItIA.L, INTERIOR LINING and CORROSION pItOT C"I'ION. <br /> 2, If OTHER,print in the space provided. <br /> FPINCI INIZORMAITON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circled or if OTHER,print in space provided. <br /> 3. Indicate the LFAIS 1311'EC-FION system(s) used to amply with the monitoring requirement for the piping. <br /> V. TANK LEAK I)E?°I'I17110 <br /> 1. Indicate the LEAK DETF C]71ON systems) used to comply with the monitoring requirements for the tank. <br /> . INFO TION ON TANK 1'UR Mull?`/I LY Ct.O SI?I)IN PIACF <br /> L F aTIMA 31) DATE LASS USED-MONVITI/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED I)QUAN rrry of I1J ZARI)OUS SUBSI'ANC E remaining in the tank(in C:aallons), <br /> 3. WAS TANK K IaII.,LE'D W1111 ISE R`I R'1r'VrT3RIAL? Check 'Yes`or'NO'. <br /> APHICAN17 MUST SIGN AND DA`T'E`I'IE IURM AS INDI(WIT0. <br /> INSTRU('110N FOR THE LOCAL AGFN(7I7—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 Board. (0916)719-2421. The facility number mustbe 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 /> FE IS'I7IE RENTONSIBILM OF'111E I AGIN. CY T" .I'1 E(7.P`S 11-117,1?AC I. I"Y T1)VER117YTHE <br /> ACCURACY 0IVn1E IN11ORMNITON. T'III 00U,AGE N(N IS RESPONSIBLE T13R TI T?COMPHalON OF'IIIE <br /> *LOCAL AGENCY USE ONLY'INI )RASA I IBOX AND MR F?ORWARDING ONE FOR 'A"'AND ASSOC °I'ED <br /> FORM-Ir(s)TOTIIE MLLOWING ADDRESS. <br /> " ,A113 011 CALIFORNIA <br /> MI 3 WMIER RES URC--S CON17ROL WARD <br /> C/o S.W.11n:,ps. <br /> DxrA mocu-,sitdo C`I I13Ti <br /> P.O.BOX 527 _ <br /> ISA OUNI',€:A <br />