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IN51'RUCHONS FOR COMPLUITNG I?ORPA.'IP A <br /> GENERAL IN,1NRUC11ONS: <br /> L One FORM "B"shall be completed for each tank for all NEW PTIRMI'lN,PERMrr CHANGES, RE*MOVAIS and/Or any <br /> other'EANK INFORMA17TON C'1 GE. <br /> 2, 'Phis form should be completed by either the PERMI`I'APPLIC"A�. or the WCAL AGENC-Y UNDFIRGgROUND'FANK <br /> INSPIXTI'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 /> 'MP OF FORM: 'MARK ONLY ONE n-im <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 /> L 'IANK DF-SC RIr11ON-COMPIEFF,ALL 1711IMS-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.A13707799), <br /> B. Indicate the name of the company that manufactured the tank(ex. &ME,TANK MFG.). <br /> C. Indicate the year the tank was installed,(ex. 1987). <br /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> II, TANK C;C)N"I1:KCS <br /> A. 1. If MOTOR VEHICLE FUEL,check box I and complete items B& C. <br /> 1 If.not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> 13. Check the appropriate box. <br /> C. Check the type of MO'I'OR 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 Cj%,S.#. (Chemical Abstract Service <br /> number), if box I is NO'I'checked in A. <br /> 111. 'TANK CONS-FRUCIION-MARK ONE lr['FM ONLY IN BOX A,B,C&D <br /> L Check only one item m'FYPE OF SYS-I'EM.'rANK MA'rl.,,RIAI,, INFERIOR LINING and CORROSION PRO'H"(77ION. <br /> 2. If 0'1'11EF- print in the space provided. <br /> TV. PIPING INIURMIVIION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 1 If UNKNOWN, circle; or if 011113R,print in space provided. <br /> 3. Indicate the LEAK DE1'l1-.C`I'lON system(s) used to comply with the monitoring requirement for the piping. <br /> V. 'IANK LEAK DUI7X-711ON <br /> 1. Indicate the LEAK DL`EC`'ION system(s) used to complywith the monitoring requirements for the tank, <br /> VL INFORMATION ON TANK PERMANEINIT.Y CIAXSED IN PLACE <br /> 1. ESTIMATEID DA'14'LAST USED -MOIN'111/YEAR(January, 1988 or 01A18). <br /> 2. ESI'IM/VIED QUANFITI"Y of HAZARI)OUS SUBSTIANCE remaining in the tank(in Gallons'). <br /> 3, WAS TANK 1111ED wriii INI10'MANURIAL? Check 'Yes'or 'NO'. <br /> APPLICANT'MU%-rSl(;N AND D/V1711111 IPORM AS INDI(11IE11 <br /> INS-fRUCIION FOR11IF LOCAL AGINCIE-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. I'lle county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)739-2421. 'I'lie 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 /> ri,IS11IE RESPONSIBI111"Y 014-11TE LOCAT. FACRYFY 11)VERIFY'nIft <br /> ACCURACY OF111H INFORMATION. '111E'X)CAL AGISNC,Y IS RIF-SPONS[131171 FOR 111H COMPLETION Oil 11111" <br /> *11)(AL AGIINC Y USE ONLY'INFORMA110N 13OX AND FOR 1k)RWARDING ONE FORM*A'AND ASSOCIN114)%, <br /> FORM'B'(s)TO 11TE,FOLLOWING ADDRESS. <br /> OF CA11FORNIA <br /> P,OBOX SZ7 <br /> PARAMOUNI',CA WrM <br />