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INSI'RUMIONS FOR COMPI.MING VORM`I3" <br /> C.iEWMAL INS1`RUCi.'(£3NS: <br /> 1., One FORM "B"shall be completed for each ±:ank for all. NEW PFAMUN, PI RMI'I'CHANGES, REMOVAI S and for an,,, <br /> other'TANK INFORMATION CHANG1 <br /> 2. This form should be completed by either lie PERMIT APPT.ICAtN C Or the LOCAL MA NCY UNDERGROUND'TANK <br /> INSPECMR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you'<bre making 3 copies. <br /> 'IY)P OF FORM:"MARK ONLY ONE r11iM" <br /> 1. Mark an (X)in the box next to the item nmt bcst describes the reason the Writ is being comple(ed. <br /> 2. Indicate the DBA or Facility name where "-;e crank is installed. j <br /> I. 'TANK DI.L%CRIPIION-COMPLETII An.rr1WS i1'UNKNOWN-SO til'^'M."I;Y <br /> A. Indicate owners tank 1I:) #-If there is r: ;ximbe:r that is us-A, ;g t!te owner, to identify the taol, (ex.A870739). <br /> B. Indicate the name of the company that r: =:tared the tank l l,l;'I'ANK MFG.). <br /> C. Indicate the year the ,,dnk was installed = <br /> D. Indicate the tank capacity in gallons (ex, etc), <br /> II. 'TANK CON:II:,NIS <br /> A. 1. If MOTOR VEHICLE I-tiF1.,check box "i and complete items B& C. <br /> 1 I£not Mo-COR VEHICLE FUEL,,check the appropriate box in section A and complete items B& D. <br /> 13. Check the appropriate box. <br /> C. Check the type ot°MOTOR VEHIC E FUM.(if box 1 is checked in A). <br /> 1). 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 NO':I'checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,13,C&1) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MN17ER.I L, INTERIOR LINING and CORROSION PRO'I'1:CI'ION. <br /> 2. If O TIIEI2,print in the space provided. <br /> W. PIPING INFORMMION <br /> 1. Circle A if above ground, circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,paint in space provided. <br /> 3. Indicate the LEAK DETE(-I'ION system(s) used to comply with the monitoring requirement for the piping. <br /> Y. TANK LEAK DIM X71 ION <br /> 1. Indicate the LEAK DEFECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PEiRMANENMY CLOS10 IN PLACE <br /> I. F.SIIMA'TED DNI'E LAST USED-MON"TTI/YEAR(January, 19fk4 or 01/88). <br /> 2. EiSTIMNITl)QUANITTY of IIAZARDOUS SUBSTANCE'remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED W rm INl:RT MA"TTRIAI.? Check 'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DNIM1711 FORM AS 1NDICtiIED. <br /> INSTRUCITON FOR THE I OC:AL AGENCIES <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 (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 Board to assign the tank number,please leave it blank. <br /> rI'IS ME RE.SPONSIBUXI'X 0111711 LOCAL AGENCY 11IAT INSPFCIS'1111 FAC-MIN TO VEiRMVIIIE <br /> ACCURACY 011111I:INFORMA`110N. TIIE?LOC'AI,AGENCY IS RESSPONSII3LE FOR'THE COMPLETION OF THE <br /> "LOCM..AGENCY USE ONLY"INFORMA711ON BOX AND FOR FORWARDING ONE FORM"A'AND A.'iSOCINIVI) <br /> FORM"B"(s)'1'O 117E FOLLOWING ADDRESS. <br /> STMIT 017 C AI.IFORNIA <br /> ST'AI`N WATER RI?SOURC13S CONTROL BOARD <br /> C/o S.W.1?I?P.S. <br /> DATA PROCESSING CENI'E:R <br /> P.O.BOX 527 <br /> :? PARAMOUNT,CA%723 <br />