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N,I.'RU(,'I'1ON,S FOR CiPMPUN`t' G IX)R 'r
<br /> UE.NERAL INS-FRUC:I:ONS:
<br /> L One FORM "B"shall he completed for each tank for all NIM PFRM3'1'S,P1 R F C:IIANGFS,. RFM(y'�
<br /> other TANK INIURMMION CHANGE
<br /> 2. `this forms could be compictcd t:.°scitlaer the PERMTrAPPI.TCANTor the LO(AI.AGI3NcY UNT)ER.E>ROUI111)
<br /> INSP1 OR.
<br /> 3. Tease t)T=^ :rz<print cleaTiv all requested information.
<br /> Use harg4,)oint writing instrumem.. you ate ntak�ng 3 cotes
<br /> 4 �Ir�p .r M*M:"KIE' k ONL CI I:&" ? "
<br /> 1. Mark all (Y,1 in the boy acxt to the item that best describes the reason the form is beim complestfed �.'
<br /> 2_ InB ic4e3theD A`or Facility name where the tank is installed. a,
<br /> `I:rS qX I:IIsb MII'"1�TCWF*I., I7!A1.1.TI S-IF I71NT1 Nf,.) N- SO SPI;&14
<br /> A. Indicate ow'nei-s;tank.Ila #. -If there is a tank number that is used by the owner to identify the tank (ex.A13707&',)).
<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). N .
<br /> D. Indicate the tank capacity in gallons (ex.2.5,000 or 10,(10(3 etc.). A
<br /> 11. TANK COM11WI'S
<br /> A. 1. if MUOR VEHICLE I3 F2,IJ1 chdcltbox I and cdmiplete itemss 9 8c C.
<br /> 2. It not :V )TOR VLIIICI,h FUEL, check the appropriate box in section A and complete items B by D.
<br /> B. Check the appropriate box.
<br /> C the type of M.O'I'OR VEHICT-F FUEL(if box I is checked in A).
<br /> D. `Ii:chemical name of the hazardous substance stored in the tank and the CA.S.#.(Chemical Abstract Se�vicc
<br /> nua�lrr), if box 1 is NO'T'checked in A.
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<br /> . ONEi'1U (-.)NIY IN 13OX A,13,C8&D
<br /> 1. Check only one item in'IYPE OF SYS11iM,TA K MATFRIAI.,, IN"IER1OR LINING and CORROSION I']2C)TEX'110N.
<br /> 2. If O'I'llE12,print in the space provided.
<br /> IV. PIPING INFO A,1'1ON
<br /> 1. Circle.A if above ground; circle I.I if underground, and circle both if applicable.
<br /> 2. If t "{" , ','N,curls or if GFHER,print in space provided.
<br /> 3. Inds . w° LEAK DI IEC 1TON system(s) used to comply with the monitoring requirement for the piping.
<br /> 4r. 'I:AN]K LEAK DITnX7110N �
<br /> L Indicate 0)e LEAK D1 I'F?CTION system(s)used to comply with the monitoring requirements for the tank.
<br /> VI. INFORMAMON ON'FANK PERMANImII,X CI.OSIo IN PI.ACE
<br /> 1. FS171MA'11,713 DATE I.,AS'1"USFD-MON'I'II/YEAR(January, 1488 or 01/88). � t.
<br /> 2. VITFIM 11,1 1)QUAN°TI'IY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons).
<br /> 3. WAS TA' FTI'—t='WCIJI INI3RT MA'IERIAL? Check'Yes'or WO'.
<br /> ANI' ""=i THE 1*t3RM/1,:i 1NDICKI IED,
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<br /> <�:�a�L h a,a'3i t^f3I8."I"1II?,�..Cyt�•^� F 4;�C'II:S
<br /> T'he state underground storage tank identification number is r; ssscd of the two digit county number, the three digit jurisdiction
<br /> number, the six digit facility number and the six digit tank r,. county and jurisdiction numbers are predete.rm ncd and
<br /> can be obtained by calling;the State Board (916)739-2421, '> -umber must be the same as shown in form 'W° I`he
<br /> tank number may be assigned by the local agenT, however, ,r;,,,.must be numerical and cannot contain an alf>!tabet, Ii
<br /> the local agency prefers the State Board to assign the tank cv I)tr, please leave it blank.
<br /> I°1'IS'1711F WISPO S11111I Y 0- :":'y ,"q"a,C'I THE ItAG'CLPI'Y ID VERIFY'ITT
<br /> AC';C L RAC`Y yta 1I1I LN3�( R ° f i t1NSII3LI IT41R,11.�C C�It� 1,1�' N Oh T1.3:,
<br /> *LOC�ML AGE<NCY USE ONLY , X "WARDING OM, I M'"A�IAI+� SSO flAil ���'.S
<br /> IX)R7 B"(.,,.'F','o ITIl IaC9I.I C) r E at.3 14.;
<br /> FIaa IE OF C61
<br /> C/0 S
<br /> DeVE
<br /> F-1.BOX 5
<br /> PARAMOUNU,CA 9M
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