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sIRUCITUNS FOR COMP1ZfTNG FORM*I3* <br /> GENERAL IN .. L7 U <br /> 1. One FCS "B"shall be completed for each tank for all NEW PERWIS,PERMIT C", NGE-1a, REMOVALS and/or.any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the I. >AGENCY UNDERGRQUND TANK <br /> INSPEC11OR- <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing,instrument,you are making 3 copies. <br /> P OF RIC ONLY ONE rITW <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 /> 1. TANK E S, TUN.-COMPLEIM ALL n :. T U -S0 SEPI? I <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"TAMC MFG.). <br /> C. Indicate the year the tank was installed(ex. 198'7), <br /> D. Indicate the tank capacity in gallons(ex.25, or 10, etc,). <br /> II. °IANK CONIIWJ ; <br /> A. 1.. If MOTOR VEHICLE FUEI.,,check box I 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 hazardoussubstancestored in the tank and the C.`.A.S.#. (Chemical Abstract Service <br /> number), if box 1.is NOT checked in A. <br /> III. TANK CONS171111(7170N-MARK U r ONLY IN BOX A,II,C:&D <br /> 1. Check only one item in'I Y E OF SVS'TEM,TANIZ MATL,'RIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If. OTHER,print in the space provided. <br /> . PIPING FUR 11ON <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 LFAIC DHIMCTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DITITt UN <br /> 1. Indicate the LEAK DI✓'TE ON system(s)used to comply with the monitoring requirements for the tank, <br /> INMRMAIION ONTANK PERMANEMIlLY CLOSEDIN PIACE <br /> L ESTIMATED HATE LAST USED`--MO I/YEAR(January, 1.988 or 01/88). <br /> 2. ESTI TED QUANTITY of HAZARDOUS SUI.IS"TANC'E remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WI7.7I-I i RTTERIAL:>Check'Yes'or'NO'. <br /> APPLICAN'I'MUST SIGN AND DATE ITIE FORM AS INDICATED, <br /> UC.ITON FOR THE L 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 fort""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 /> IT IS THE RESPONSIBII.XN OF TIII:,IMAL AGENCY ITIAT INSPE.CI1i TIII:i FAC:IIXI'Y TO VERIFY111E <br /> A, C'Y OF'IIM INFORMAIION. °ITII?LOCAL AGENCY IS NPONSIBLIi FO 111E COMPLY111ON OF 17113- <br /> "LOCAL <br /> IIE*I .AGENCY USU UNI. *I: r'UR 'ITTUN BOX AND ISR FORWARDING ONE F()R *A*AND A,SSOC"I)VI"I D <br /> FORM'fr(s)TO:ITIS;FOLIA)WING ADD <br /> ,STATE OF CALIFORNIA <br /> 9DV113 VAIMR, I- URCHS C ONFROL BOARD <br /> C/o s, nl <br /> DATA PROCE&RNG CENTER <br /> P.O.BOX 527 <br /> OUN.T,CA 90M <br />