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' ��1 _ �r�#��I s � -:;�'�„s. ,:°'.��aT,-'' a�&�` c�" ,. '+#�w��,'��5�,.�:'t 't»,.� +""�9;=s:r"-��r n t+�sl'"`r�rr��•�.3C w� -r ??* !� <br /> IN,%,rRUC`I1ONS FOR COMPI.JgJN6 IZORM 113' • <br /> GI"sN1?RAF..LN;>I'Rtj<<� <ON�s: <br /> 1. One FORM "B"snail be completed for each tank foe all NEW PV'11M1'LS,PERMJ'I'(3HANGES, REMOVAI.s and/or az,v <br /> other'rANK INFORMN11ON CHANGE, <br /> 2. This form should be completed by either 4 he PERMTr APPIIC:AN C„r the LOCAL,AGHNCY UNDERGROUND TANK <br /> INSPi?CTOR <br /> 3. Please type or print clearly all requested info-nation. <br /> 4. Use a 'hard point writing instrumenC,'you are making 3 copies. <br /> 'I'OP OF.FORM-'MARK ONLY ONE II14M' <br /> 1. Mark an (X)in the box next to the item tat<<.t hest describes the reason the form N'being completed: <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. "LANK DESC:RIPIION-COMPI-FIV A11,171'EMS iI'IL NKNOWN-SO ai`1'tt::" <br /> A, Indicate owners tank 11:) #-If there is� "nmbe:r that is us,,A ;,y t!ae owner to identify the tank (ex.A1370789). <br /> B. Indicate the name of the company that n,-- ured the tank(.. '11"I'AtiK <br /> C. Indicate the scar 033, ink was installed . "3, <br /> 1.). Indicate the tank capacity in gallons (ex : ,r 10,000 etc)- <br /> 1i. 'TANKCONI1WIN <br /> A. 1. Ifb101'01Z VEHICLE FUEL,check box 't and complete items B& C. <br /> 2.If not MOTOR VI:IIICLE FUEL,check the appropriate box in section A and complete items Ii R 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEl,Qf 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 1 is NOT checked in A. <br /> I <br /> 111. TANK C ONSFRUCI'ION-MARK ONE 1111M ONLY IN BOX A,13,C&c D <br /> 1. Check only one item in'IYPF,OF SYSI'EM,'TANK MA'T'ERIAL., INl'ERIOR LINING and CORROSION PRO'11:C`IJON. <br /> 2. If 011113R,print in the space provided. <br /> IV. PIPING INFORMA11ON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if GHTER,print in space provided. <br /> 3. Indicate the 1, K DL1'EC'I1ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEIMC:IION <br /> 1. Indicate the LEAK DE I'ECTION system(s) used to comply with the monitoring requirements for the tank_ <br /> VI. INFORMA11ON ON TANK PER.MANEN11Y CLOSED IN PLACE <br /> 1. ESTIMATED DA`I7E' LAST USED-MON-171 I/YEAR(January, 1988 or 01/88). <br /> 2 ESTIMA"I7ED QUANTITY of TIAZARI)OUS SU1.3S;1'ANCE;remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WI'I ll INER"l'MA'1`ERIAI.;7 Check'Ycs'or WO'. <br /> APPLIC:ANI'MUST SIGN AND DA171:?'LITE FORM AS INDICA I3?D. <br /> INSI'RUCTTON FOR,mv,LOCAL 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". 'ne <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 /> rl'IS TIIE RESPONSIBUX17Y 017711E LOCAL.AGENCY 11IA'1`INSPEC N 1`111-.FAC IL11Y TO VERITY 11IE <br /> ACCURACY 01 'I1IE INFORM '110N. 1111.1 LOCAL AGI:?NC:Y IS RFSPONS111I1i FOR11I11 C OMPHNION 017'1111 <br /> 'LOCAL.AGENCY USE ONLY"INFORMATION BOX ANI)FOR FORWARDING ONE FORM"A'AND ASSO(:I ITiD <br /> FORM'I3"(s)1'0711E FOLLOWING,ADDRF-SS. <br /> STA11 OF CALIFORNIA <br /> SIWII!WAITER RFSOURCLS CONTROL BOARD <br /> C/o smxuips. <br /> DATA PROC'INSING CI:WI'ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />