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INSI'RUCIIONS FOR COMPLHIING FORM"B" <br /> GFMRAI w INSMUC171ON& <br /> 1. One FORM"13"shall be completed for each tank for all NEW PERMnS,PERMYr Ct NGE!1, REMOVALS and/or any <br /> other TANK IN17ORMATION CIIANGR <br /> 2. This form should be completed by either the PERWr APPLICANT or the IMAL AGENCY UNDFRG OUND TANK <br /> INSPECrOR. <br /> 3. Please type or priest clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> P OF .a i£CJ .Y ONE , " <br /> 1. Dark 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 /> 1. TANK 1CAEk" . 7ON-COMPTE17 All,rl'B -IF UNKNOWN-SO SI'I? <br /> A. Indicate owners tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.AB7€1789). <br /> B. Indicate the name of the company that manufactured the tank(ex.AC METANK MFG.). <br /> .). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25, or 10,000 etc.). <br /> 11. 1`ANK CONTENTS <br /> A. i. If MOTOR Y'F IIICLI FUEL,check box I and complete items Il&C. <br /> 2. If not MOTOR VFHICLII FUI;L,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. Forint 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 NOT checked in A, <br /> M. TANK CONSTRUCTION-mARK oNF.rn . ONLY IN BOXA,I3,,C:&D <br /> 1. Check only one item in TYPE OF SYS'I'13-M,TANK MATERIAL,IN4"I'E RIOR LINING and CORROSION PROTEC7ION. <br /> 2, If OTI-ILI2,print in the space provided. <br /> . PIPING INFORMN11ON <br /> L Circle A if above ground;circle U if underground;and circle Both if applicable. <br /> 2. If UNKNOWN,circle; or if 01111-711,print in space provided. <br /> 3. Indicate the LEAK DL;I'F C'IION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEFECTION <br /> 1. Indicate the LEAK DE ITC'TION system(s)used to comply with the monitoring requirements for the tank. <br /> . IMDRMA71ION CAN TANK PERMANi3mmy CLOSED IN PLACE <br /> 1. M '11'1;1) DATE LASTUSED-MO; IJYEAII (January, 1988 or 01/88). <br /> 2. ESFIMATED QUANTITY of IIAI,AIWOUS SUI3SSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED 1td17I11 INIIIC'I` 11:17RIAL?Check'Yes'or'NO'. <br /> APPLICANI'MUS17; GNAND A ' . >I' 7TD; <br /> Ill UC ON 1K)R`I11E LOCAL AGFN S <br /> The stateunderground 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". 'I'he <br /> tank number may be assigned by the local agency; however,this number must be numerical and cannot contains an alphabet. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT IS'IiIf?REspoNSIBigzff(IFS nw-Im-AL AGiNcy'IIIA:T INSPFcI s°ITI13 FA(,MrrY TO VERIMVIIIE <br /> ACCURACY GAITTII?INFORMIVIION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR ITIE CO PINI`ON 012 THE <br /> .AGENCY GEN USE ONLY'INFORMAITON BOX AND MR FORWARDING ON13 ISO "V AND ASSOCIM1170 <br /> FORM-W(s)TO-111H FOLIA-)WING ARIA RFSS. <br /> KI`E- OF F NIr1 <br /> 5IAIV,WNIIIR 1111` U RCES C4 NI'1 OL BOARD <br /> C/o S. .ILI?p.S. <br /> DATA PROCESSING SSING CINI`ER <br /> P.O.BOX 527 <br /> PARAMOUNI7,CA 90723 <br /> �t",4"AW"14d;' ft"", <br />