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. .::T'�'"'ti' w*F.+ne'rr.-•'"�?,r?r'"ers��'g'"'%1�r"'yT,'3!�"'*1�i+7C'�.`-, +^ �f.`j°�4 °'sl�+Af. ,�*'�.�n7'"`vpgi' ...'.'"c'a.,.",'ky «"".�gC?'�e:l'ari"�"°'r�s':"�s�.�ev-i <br /> 1` <br /> INS RUC:11ONS FOR COMPLETING FORM"I3" <br /> w <br /> GENERAL INSTRUCTIONS: <br /> 1.. One FORM"B"shall be completed for each tank for all NEV PERMI'I.:S,PERMIT CEIANGE S, REMOVAI:S and/sir any <br /> other TANK INIX)RMA']ION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI ICAN'I'or the LOCAL AGENCY UNDERGROUND 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 /> TOP OF FORM:,"MARK ONLY ONE mw* <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 /> I. TANK DE:SCRIVITON-COMPLSET?AI.,I,1113MS-IF UNKNOWN-SO SPECIFY r <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <br /> B. Indicate the nope of the company that manufactured the tank(ex.ACME..,TANK MFG.). <br /> C. Indicate the yeprthe tank was installed(ex. 1987). r <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000-vtc.1). <br /> 11. TANK CONIENTS <br /> A. 1. If MOTOR VEIIIC:E FUEL,check box 1 and complete items I.3&C. <br /> 2. If not MOTOR VEHICLE: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 VE?HICL 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 AbstrService <br /> number),if box 1 is NOT checked in A. <br /> 111. TANK CONSTRUCIION-MARK ONE ITEM ONLY IN IiOX A,13,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTI..CTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> L Circle A if above ground; circle U if underground;and circle both if applicah e. <br /> 2. If UNKNOWN,circle; or if OTIIER,prinvin Vace provided. <br /> 3. Indicate the LEAK DETIICTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLrrF(:11ON <br /> t 1. Indicate the LAK DEiII C'TION system(s) used to comply'With the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANI:WI7 Y CLOSED IN PLACE <br /> 1. FSTIMAITI) DATE LAST USED -MONTII/YEAR(January, 1988. or.01/88). <br /> 2. F9:1IMATI3D QUANTCTY of HAZARDOUS SUBSI'ANC:E remaining in',the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MA':1;RIAI..?Check'Yes'or'NO'."t <br /> APPLICANT.'MUST SIGN AND DAR?111E FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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. The facility number must be the same as shown in form "A". 'Che <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 Sta+e Board to assign the tank number,please leave it blank. <br /> IT'IS11IE RESPONSLBITXI'Y OF 111E LOCAL AGENCY TEIAT INSPECL:S 111E FACILITY TO VERM" '11ff? <br /> ACCURACY OF111E INFORMA.IION. TME LOCAL AGENCY IS RFSPONSIBI.,E FOR 111E COMPII 11ON OF 111E <br /> "LOCAL AGENCY USE ONLY"INFORMATION Box AND FOR FORWARDING ONE FORM"A"AND ty:4OO(IN EiD <br /> FORM'B'(s)TO TH.E FOLLOWING ADDRESS. <br /> ST)V3171 OF CALIFORNIA <br /> SIAM WA'I'EiR RESOURCES CONMROL BOARD <br /> C/O S.W.EE P.S. <br /> DATA PROCESSING (MN`rFR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />