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INSTRUCTIONS FOR COMPLETING FUR <br /> GENERAL INSIRUCTIONS: <br /> 1. One FORM"I3"shall be completed for.each tank for all NEW PERMII�i PI RM[T CHANGM REMOVALS and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2 This form should be completed by either the PERMIT APPI 1CANr or the LOCAL.AGENCY UNDERGROUND TANK <br /> INSPECCOR <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 ONL ITEM" <br /> L Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicatf the DBA or Facility name where the tank is installed. <br /> 1. TANK DESCRIPTION-COMPLVFP ALL ITEMS-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 name of the company that manufactured the tank(ex.ACME TANK MPG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,(W or 10,000 etc.). <br /> H. TANK CONT PN.FS <br /> A. 1. If MOTOR VEHICLE FUEL check box I and complete items B& C. <br /> 2.If not MOTOR VE'IIICLE 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.S4.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> M. TANK CONSTRUCTION-MARK ONE r1IW ONLY IN BOX A,B,C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MAT'ERIAI„ INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> N. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle, or if(TIMER,print in space provided. <br /> 3. Indicate the LEAK T?ETECI'ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETI?.C)[ON <br /> 1. Indicate the LEAK DEFEC.`FlON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANFNFLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WH II INERT MATERIAL?Check'Yes'or'NO'. <br /> APPI1CPkNr MUST SIGN AND DA"IR TEII?FORM AS INDICATED. <br /> INSTRUCTION FOR'TILE 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. 'C'he 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 /> IT'IS THF?RFSPONSIBIIX Y OF TIED LOCAL AGENCY THAT INSPECTS TILL FAC TI.II Y TO VERIFY TTIE <br /> ACCURACY OF THE INFORMATION. 'IIIE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TILL <br /> •LCK'AL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE.FORM•A"AND A--SSOCIATED <br /> FORM-W(s)'M'ITIE FOI.,COWING ADDRESS. <br /> S 7A:FE OF CAI IFORNIA <br /> STATE WA TIER RESOURCES CONI'ROL BOARD <br /> C/O S.W.F?E.P S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />