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INSI'RUCIIONS IX)R COM.PLVnNG A"B" <br /> GENERAL INSTRUCTIONS' <br /> 1. One FORM"I3"shall be completed for each tank for all NM. PERMTI'S,PERM[I'CHANGES, REMOVALS and/or any <br /> other'TANK INF ORMAIION C:I IANGE. <br /> 2. This form should be completed by either the PERMTr APPI.IC.ANI'or the LOCAL AGENCY UNDERGROUNDTANK <br /> INSPF..0 MR. <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 TI73M" <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 DHSCRIVIION-COMPLI?ITi ALL TI't?MS-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'1ANK?MFG.), <br /> C. Indicate Abe year the-tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). <br /> H. TANK CONI 4 <br /> A. 1.. If MOTOR Vl?I IICLI FUE 1,check box 1 and complete items B&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 VEHICLE 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 Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> IIL TANK CONST'RUCTION-MARK ONE rI1W ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE 01'SYSTEM,'TANK MATERIAE.,, INTEIRIOR INNING and. CORROSION PROTEC11ON. ' <br /> 2. If OTIIEk, print in the space provided. <br /> IV. 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 011114K print in space provided. <br /> 3. Indicate the LEAK Dh! F(`TION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVI'FC'I'ION <br /> 1. Indicate the I,I;AK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANf3NI1.Y CLOSED IN PLACE <br /> 1, ESTIMATED DATE LAST USED-MON71I/YEAR(January, 1988 or 01/88). <br /> 2. 1STIMAI'I D QUANT1I7Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wrni INERT MATERIAL?Check'Yes'or':STC)'. <br /> APPLI ' MIJSI''SIGN AND DNn-3'11IF FORM AS INDIC..AIM. <br /> INSTRUCIION FOR'11IL 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(91.6)739-2421. The facility number must be the same as shown inform"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 /> TT IS T1IE RFSPONSIBIIIIY OF TIIE LOCAL AGENCY THAI'INSPECI'S'111E FACILr1Y'I`O VERIFY TILE <br /> ACCURACY OF TI IIi INFORMATION. 11IE LOCAL AGENCY IS RESPONSIBLE FOR 111E COMPLETION 01731111 <br /> "LOCAs.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM"B"(s)'J'O 711E FOLLOWING ADDRF.S.S. <br /> SPAI1t OF CALIFORNIA <br /> SIWI'E WAI13R RESOURCES CONTROL BOARD <br /> C/O S.W.E E.P.S. <br /> DATA PROCESSING CEN`t`ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />