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.... <br /> INSt RUCI1ONS FOR COMP1.1, C,F O "F3" <br /> GENFRAL INSfRIXCl10NS-1 <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMr? t^:Fz� z t't:IFANC:PS, RFMOVAI.S and/or any' . <br /> other TAMC INFORMATION CIIANGI? <br /> 2. This form should be completed by either the PERMTT APPLICANT or the 1,0CAI,AGENCY UNDERC,ROUND TANK. <br /> INSPP.CMR. <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 TrEM" <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 DI3A or Facility name where the tank is installed. <br /> 1. TANK DESCRIPTION-COMPLUFF ALL r1'EMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11)#-If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the lhame of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1.987). <br /> D. Indicate the tank capacity in gallons (ex.25,000 or 1,0,000 etc.). <br /> 11. TANK CONI7?NIS <br /> A. 1. If MO'T'OR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE FULL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MO'T'OR VEHICLE FUEL(if 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 /> III. TANK CONST'RUC`TION-MARK.ONE r1EM ONLY IN 13OX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYS'iT?M,TANK MATERIAL,IN F.RIOR LINING and CORROSION PRO'[EcnON. <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING INFORMA'ITON <br /> 1. Circle A if above ground; circle LJ if underground; and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECI'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LIQ DE717GT10N <br /> 1. Indicate the LEAK DEI'I:3CT'ION systems) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PIACH <br /> 1. ESIIMXITD DATE LAST USED-MON'TH/YI::AR(January, 1988 or 01/88). <br /> 2. FSTIMATED QUANTITY of HATARDOUS SUBSIANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK F IIJ,ED WI'Tl INER"I'MA'T'E RIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DAT7:111E FORM AS INDICWI'E D. <br /> INSTRUCTION FOR 711E LOCAL AGEN(.'TE;S <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 RESPONSIBILT'TY OI"Dill LOC'AI, ll W FAC'ILr1Y TO VFRIh"X'T'11I3 <br /> ACCURACY OF 11°11?INFORMXI1ON. 111E LOCAL+5GFNC,Y 14 RF',SP0NSi1; FOR'I11E COMPI..I:I'ION OF IIIE <br /> 'LOC.AI.AGENCY USE ONLY*INFORMNI10N 1 )X AND FOR FORWAF2F7F,'+G ONE FORM "A"AND ASSOCIATED <br /> FORM'B"(s)-1701`1111 FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STA'I1?WNIER RESOURCE-S CONTROL BOARD <br /> C/O S.Wju:? ',S. <br /> DATA PROCESSING C ENIT?R <br /> P.Q.BOX 527 <br /> PARAMOUNT,CA WM <br />