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f"tte <br /> 41 <br /> P, <br /> 0 <br /> INS`I'RU('I10N,S FOR COMPLInANG FORM*Ir <br /> GENERAL INSFRUCilONS: <br /> L One FORM 11"shall be completed for each tank for all NEW PV,1MTI.'3.,PERM171'CIIANGES, REIMOVA[S and/or ar?v <br /> other TANK INFORMA`110N CHANG11 <br /> 2. This form should be completed by either he PURmir APHICANC i)r the LOCAL AGENCY UNDERG'ROUND TANK <br /> INSPECI)DR. <br /> 3. Please type or printclearly all requested information. <br /> 4. Use a hard point writing instrunient,'youvre making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE ram <br /> L Mark an (X) in the box next to the item inV)est describes the reason &1brin is being completed. <br /> 2. Indicate the DBA or Facility name where tl;-e tank is installed. <br /> 1. TANK DfiNCRIV110N-WMI'LITIV All.rll". S., X'UNKNOWN-SO SI'E(,.If?Y <br /> A. Indicate owners tank 11.) #-If there is ztr�rl`i ;;umber that is w,�d tie owner to identify the tank (ex.A1370789). <br /> B. Indicate the name of the company that r .urcd �the tank <br /> C. Indicate the year the tank was installed o11 <br /> D. Indicate the tank capacity in gallons, (ex, !0,0(x)ctc <br /> AL TANKCONI`HNI`S <br /> A. L If MO'I'OR V13L11CLE FUEL,check box i and complete items 13 & C. <br /> 1 If not MOTOR VL111CLE FUEL, check the appropriate box in section A and complete items B & 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FU1.1,Pf box I is checked in A), <br /> D. Print the chemical name of the hazardous substance stored in the tank and the (.A,S.#. (Chemical Abstract Scr6ce <br /> number), if box I is NOT checked in A. <br /> III. TANK(7ONS17RUCITON-MARK ONE rIT!M ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in TYPE OF SYS`1'13M,TANK M/VFERJAL, INTERIOR LINING and CORROSION PRO'11:,'CIJON, <br /> 2. If 0`111FR,print in the space provided. <br /> IV. PIPING IWORMN11ON <br /> L Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided, <br /> 3, Indicatethel, K DL717EMION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DIr11XT11ON <br /> 1. Indicate the LEAK DE-fECUION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INfURMYVIION ONTANK PIFRMANE NII.Y CIA)SEID IN PLACE <br /> 1. FSITMATED DATE 1ASTUSED-MOMII/YEAR (January, 1998 or 01/88). <br /> 2. ESTIMATED QUANTITY of TIAVARDOUS SUBS'I'ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WrlI I INERTMATL,RIAL? Check 'Yes'or'NO'. <br /> APPLICANT MU91'SIGN AND DATE THE?FORM AS INDI(WIE13, <br /> IN,M17RUC17ON FOR 11111 LOCAL AGFNC <br /> The state underground storage tank identification number is composed of the two digit county number, tie 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 maybe 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 /> rl'IS UIE RESPONSIBILrFY OFTHE LOCAL AGENCY`1T1A`I`INSPEC-t`S'I11I- FACT111"Y 110 VERIFYTHE <br /> ACCURAC'Y 017T1iE INfk)RMA'.I.'ION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR'1111!COMPLEITON OFTHE <br /> *IA)CAL AGENCY USE ONLY'INFORM/VITON BOX AND FOR FORWARDING ONE FORM W AND ASSOCIA7.111) <br /> FORM-B-(s)-ionm MITOWING ADDRESS, <br /> STA'1714"OF CALWORNIA <br /> WA'1T.R RESOURCES CONTROL BOARD <br /> C/o S.W.E.E.P.S. <br /> DATA PROCHSSING CENIER, <br /> P.O.BOX 527 <br /> PARAMOUNT',CA wm <br />