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XNS'I'RU(3IONS FOR")MPIJUING POR "13" <br /> GENERAL INS'I'RUCnONS: <br /> L One 1,'ORM "B"shall be completed for each tank for all NVIN PERIVITIN,PE.RMIF I'CHANGES, REMOV`U,S ind/or any. <br /> other TANK.INFORMATION CTIANGE. <br /> 2. 'I'his form should be completed by either the PERMIT'APP11CANr or the IX)CAL AGENCY UNDEWGROUND TANK <br /> INSPECI'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 nmW <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 /> 1. 'I'ANK DF-SCRHYITON-eOMPIXFV ALL 1711IMS-117 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.ACMILTANK MF(3.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> 1). Indicate the tank capacity in gallons(ex.15,000 or 10,000 etc.). <br /> 11. 'TANK(X)N1TN`V% <br /> A. 1. If IMOTOR VEHICLE FUEL,check box I and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items 13 & D. <br /> B. Check the appropriate box. <br /> C. Check.the type of MOTOR VEHICLE FUl."I.,(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 /> 111. TANK CONS1RUC31ON-MARK ONE r.17.7M ONLY IN 13OX A, B,C,&D <br /> 1. Check only one item in TYPE 017SYSTEM,TANK MNI'l-IMIAL, INFERIOR LINING and CORROSION PROTECTION, <br /> 2. If O'DIFA. print in the space provided, <br /> IV. PIPING INFORMIV170N <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN.circle: or if OTHER, print in space provided. <br /> 3. Indicate the LEAK DETE(.711ON systcm(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LIAK DEllX11ON <br /> I. Indicate the LEAK D11r.r.,01ON system(s) used to cordply'with the monitoring requirements for the tank. <br /> VL INFORMATION ONTANK PERMANIWI7.Y(11,0SED IN PLACI� <br /> 1. ES7'1MA11. DA'IT,I AST USED-MON III/YEAR(.January, 1988 or 01/88). <br /> 2. [SI'IMATED QUAN7ITFY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 1 WAS TANK FATED wrm INY3RTMAn.,A]AL? Check 'Yes'or'NO'. <br /> APPLICAN717 MU517SIGN AND DA'm*111E.FORM AS INDICKITI), <br /> IN,1WRUCI1O1N MR'ITIS LOCAL AGENC11-14 <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. 'llie 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'][S'111131 RF-SPONSIBILLIN OF'IIIE LOCAL AGI31N(—YTIIATlNSPIXN`S TIIE FACII.Xff TO VERTF-i THE <br /> ACCURACY OF T1113 INFORNINHON. 111E AGENCY IS RESPON,1131111131*FORTIII,?COMPIXFFION OF 1111; <br /> *1,(XAI..AGEN(W USE ONLY'INFORM.N11ON BOX AND FOR 1`ORWA RIA NG ONE K)R).%4'A*AND ASSOCINITAY <br /> 17ORM'B'(s)TO 111E 11011,A)WING ADDRESS. <br /> STNI'F,OF(WIFORNIA <br /> FA'M WA iTT, R,F1S0'UR,­,,S e,Y"N­T <br /> P(i 130X 52`7 <br /> PARAMOUN71',CA%ra3 <br />