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INSYRUC11ONS FOR COMPLITEING F*M'B'
<br /> G N]FIR 1L INSTRU I"IONS.
<br /> 1. One FOR "I3" shall be compicied for each tank for all N_ PERM.171N, IERmrr CHANGES, I3MOV. I;and/or any
<br /> other TANK INIFO N11ON(;I NGF
<br /> 2. This form should be completed by either the PFRM.rr APPLICANr or the LOCAL AGFN., UNDERGROUM)TANK
<br /> 11ISVRC"`C3I2.
<br /> 3. Please,type or print c€early all requested information.
<br /> 4, Use a hard point writing instrument,you are snaking 3 copies.
<br /> OF X)II .OMARK ONLY!)N 1 uIlm*
<br /> 1. Mark an (X) in the box next to the itern'that best describes the reason the force is being completed.
<br /> . Indicate the DIIA or Facility name where the tank is install.cd.
<br /> L TANK DES 2 1 €)N-COMFLEFF All,YFEMS-IF UNKNOWN-,SIX_
<br /> A. Indicate owners,tank 11)#®If thea is a tank number that is used by the owner to identify the tank (ex.A1370799).
<br /> , Indicate the name of the company that manufactured the tank(ex.ACMETANK MI=`C1.).
<br /> C. Indicate the year the tank w-as installed (ex. 1%7),
<br /> 11 Indicat;site tank capacity in gallons(ex.25,000 or;10,0etc.).
<br /> A. 1. If MOTOR VF1llC:LE FUf'L,check bot l and complete items 13 &C:,
<br /> • 2.If not MOTOR VI�LIIC LE FUF'1L,cheek the appropriate box in section A and complete items B& D. -
<br /> B, Check the appropriate box.
<br /> C. Check the type of MOTOR VE STC I F<FUEL,(if box 1 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 Service
<br /> rc tuber),if box 1 is NOT checked its A.
<br /> III. "i",ANK C:O IRLIC 7,11ON-MARK ONE 17.1-EM LY IN 13 OX A,13,C:&I3
<br /> L Check only one item in,TYPE O SY 7 LI ,'IANK MA'I`f'slCIAL, INI173RIOR LINING and CORROSION PROTI C`PION.
<br /> 2, If C)TF I'11, print in the space provided.
<br /> IV. PIPING INFORMATION
<br /> I. Circle A;f above ground; circle;t7 if undergrounds and circle.both if applicable.
<br /> 2. If UNKNOWN,circle; or if(?'I`IIFR,print in space provided.
<br /> 3. Indicate the LEAK DI-1 ,C71ON syinent(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK IJM DVIE(7110N
<br /> 1. Indicate the I,T',A C;rla`1.('I1ON syste (s) used to comply with the monitoring requirements for the tank.
<br /> VI, INIY) A:'I10N ONTANK PER A E IM C I?I)IN PL C 1'
<br /> . RS'11MA T-D DAIT,LAST USED—MON-1711/YEAR (January, 1988or01/88),
<br /> 2. I`sSTIMA`[`I I)QUAiL711Y of HAZARDOUS SUBS'I`ANCE remaining in the tank(in Gallons).
<br /> 3. Wi6'LANK FILLED WITH INEI2`I`'M.N'C'EliIAL? Check'Yes'or'NO'.
<br /> APPI.I °. 1 U I°SIGN AND I)A 1? III:FORM AS 3NI)IC NI'3.I).
<br /> INNS U(n ION It,I 1 LOCAL.AGENCHYN
<br /> The state underground storage tank'identification number is composed of the two digit county number, the three digit jurisdiction
<br /> number, tbe 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 (916)739-2421. The facility number most be the sante as shown its form "A". The
<br /> tank number rust} be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If
<br /> the Kcal agency,prefers the State Board to assign the tank number,please leave it blank:
<br /> P I TIIE RESPONS19111.11 'OF IIIA LC)t:AL AGEN(' 11 I'INSI'M,'S"I 1E FAC,ILr Y°I'(3 VERIFY T111i
<br /> AC C ()Ir TIIL;INItC) I IC3N. III?LO(:AL AC¢FNt' I s RESP )NSIBLE FOR"71E C OMP1 i® ON OF'I1I1,
<br /> `I :AI,AGENCY USE ONLY'INFO < 'TC73 AND FOR R)RWARDING ONE FORM W AND A4"' JfED
<br /> S"""iia"I I"s OF CAMFORNIA
<br /> I IATA I"ROC. S"I CI .I`IC §
<br /> }
<br /> P.O. 13OX 527
<br /> PARAMOUNr,CA 90723
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