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INti1R(X:110NS FOR COMPL rl' o FORM I3" <br /> 1. One FORM "B"shall be con plceted for each tank for all NEW PERMT 3, VERMfI`CITANGF.S, RF.MOVA1S and/or any , <br /> other TANK INIY)RMNI10N CUANC"rl? <br /> 2. This form should be completed by either the PERMIT APPLICANT or the]LOCAL AGI.WCY UNDERGROUNDTANK ' <br /> IN:SPI?lCI`OR. <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 ONI Y ONE ITEM" <br /> 1. Mark an(7C) 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 DESCRIPTION-MMPLITrE ALL IIT3MS-IF UNKNOWN-SO SPF"'Y <br /> A. Indicate owners tank Il:) #-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 year the tank was installed (ex. 1.987). 1 <br /> D. Indicate the tank capacity in gallonir(ex.2.5,000 or 10,000 etc.). <br /> IL TANK CON1VN`1'S <br /> A. 1. If MOTOR VEHICLE F'UI:?L,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. Cbeck the appropriate box, <br /> C. Check the type of MOTOR VERICLE 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 /> III. TANK C ONSTRUC11ON-MARK ONE riEm ONLY IN 130X.A,B,C&D <br /> 1. Check only one item in TYPE OF SYSIU71M,TANK MATERIAL,PNTIT.RIOR LINING and CORROSION PRb'I13C17C)N. <br /> 2. If OT1113R,print in the space provided. <br /> LV. PIPING INFORMA"17ON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if CUTER,print in space provided. <br /> 3. Indicate the LEAK DFrEC1'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. 'T'ANK I,FAK DI?113C:`11ON <br /> L Indicate the LEAK DEsMN31ON system(s) used to comply with the monitoring requirements for the tank. <br /> V'1. INFORMATION ON TANK PERMANENI'LY C1,0SED IN PLACE <br /> 1. E911MA11.1) DATE I.AS'r USL I:) -MONTII/Yf:.AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of LIA%ARI)OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS':TANK FILLF.D WITH INF'.f f`MATI:RIAI..? Check'Yes' or'NO'. <br /> APPLICANT'MU,I Ir SIGN AND DX113'1W,FORM AS INDICATED. <br /> IN91`RUC170N FOR'11113 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". '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 /> rl'IS THE RESPONSIBIl IIY OF 17111 LOCAL,AGENCY TIIA'L"INSPI:C'1 S'II IE FACILIt'Y TO VERIFY T1113 <br /> ACCURACY 017 ITIS INFORMATION. TI1V LOC.A.I,AGENCY IS R[NPONSIBLE FOR 111E COMPII:iI1ON OF"ITIS <br /> "LOCAL AGENCY USE ONLY*INFORMATION IX)K AND MR H3I»'WARDING ONE FORM"A"AND ASSOC IAIVJ) <br /> FORM"B'(s)-1011111 FOLLOWING ADDRESS. <br /> STATE 017 CAIIFORNIA <br /> STA 17`?WXI14,R RI?.''sOURCF— CONTROI,BOARD <br /> C/O S.W.1111P.S. <br /> DATA PROCI:SING C13NIER <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />