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0 <br />IN-SIRUCITONS FOR COMPLErrING FORM *13" <br />GENERAL INS 1RUC11ONS: <br />1. One FORM ".B" shall be completed for each tank for all NEW PERMTTS, PERMIT CHANGF-S, REMOVALS and/or any <br />other TANK. INFORMATION CHANGE. <br />2. This form should be completed by either the PERWI'APPLICANI'or the LOCAL AGENCY UNDERGROUND`I'ANK <br />INSPECTOR. <br />3. Please type or print clearly all requested information. <br />4. Use a hard point writing instrument, you are making 3 copies. <br />TOP OF FORM: 'MARK ONLY ONE 1717EW <br />1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br />2. Indicate the DBA or Facility name where the tank is installed. <br />I. TANK DES CIVITON - COMPLU17H All. TrFMS - IF` UNKNOWN - SO SPECIFY <br />A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789). <br />B. Indicate the name of the company that manufactured the tank (ex. ACME 'TANK MFG.). <br />C. Indicate the vear the tank was installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,00) ctc.). <br />H. TANK (X)NTFNIN, <br />A. L If MOTOR VEHICLE FUEL, check box 1 and complete items B & C. <br />2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & D. <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE FUEL (if box I 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 />Ill. TANK CON-5.1'RU(71ION - MARK ONE r" ONLY IN BOX A, B, C & 1) <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION .PRO"TECT"ION. <br />2. If OTHER, print in the space provided, <br />IV. PIPING l[NIZORMA711ON <br />1. 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. Indicate the LEAK DFIFEM-ON system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DLqTX'IION <br />1. Indicate the LEAK m.*?.TECTION system(s) used to comply with the monitoring requirements for the tank. <br />VT. INFORMATION ON TANK PERMANEMMY CLOSED tPLACE <br />I. ESTIMATED DATE LAST' USED - MONTI I II/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WFFIT INERT MATERIAL? Check 'Yes' or 'NO'. 0 <br />APPIICAMf MUST SIGN AND DATE 111E FORM AS ININCATED. <br />INS717RU(711ON FOR 711E 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". 'Die <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 />rr IS THE Rv-sTomswuny OF wE wm AGENCY THAT INSPIR717S 111H FACIIXIT 11.) VERIFY 11111 <br />ACCURACY OF 111E INFORMA710N. 171E 1,(X:1L AGINC Y IS RESPONSIBLE FOR 1111.1 COMP11111ON OF'IIIE <br />'LOCAL AGENCY USE ONLY' INFORMA'11ON BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED <br />FORM 'B'(s) TO 111:13 FOLLOWING ADDRESS. <br />STATE OF CALWORNIA <br />sr)V-Tj*ATP,R RISOORCtIS ,CT)NIMOL wmmn. <br />C/o <br />DATA PROCESSING (2W17ER <br />P.O. BOX 527 <br />PARAMOUNI-, CA 90723 <br />