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INI.IORUCIIONS FOR COMPI.FMNG A*fr • <br /> GENERAL IN4I'RUC`IIONS: <br /> L One FORM"B".shall be completed for each tank for all NEW PE? 'Sq PERMIT CHANGF-S, REMOVALS and/or any <br /> other'I'ANK INFORM/ 10N CHANGE. <br /> .2. This form should be completed by either the PERMIT APPLICAN.I'or the LOCAI.,AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> '11OP OF FORM. *MARK ONLY ONE rnw, <br /> L 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 DESCRIPTION-COMPI-FIV,ALL TITMS-IF UNKNOWN-SO SPECIFY <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 name of The company that manufactured the tank (ex.ACMETANKMFG.). <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 /> H. TANK CONT FNIN <br /> A. 1. If MOTOR V1.111CLE IUEL,check box I and complete items 13 &C. <br /> 2, If not MOTOR V1.7.111CLE 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 stared in the tank and the CA.S.#.(Chemical Abstract Service <br /> number), if box I is NOT checked in A. <br /> HI. TANK CON91'RUCIION-MARK ONE r11N ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE,OFSYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER, 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(TI1IFF,print in space provided, <br /> 3. Indicate the LEAK Di.7,ITX'1'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK 11!AK DE V.C`nON <br /> 1. Indicate the ITAK D E'FCJ1ON system(s) used to comply with the monitoring requirements for the tank. <br /> V1. INMRMAIION ON TANK PERIVIANFNI7,Y C1X)SFD IN PLACF <br /> 1. FSIIMATED DATE LAST USED- MON111/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED wrni INERT MATERIAL?Check 'Yes' or'NO'. <br /> APPLICANT MUSTY SIGN AND DATE TIES FORM AS INDICATED. <br /> IN%-IRU(71TON FOR 111E 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". 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 /> 7 'ILITY YJ VERITY Irl'IS THE RESPONSTBHXI'Y OF 11-ILT U)CAL AGENCY THAT INSPECIN 11 IL FAC '1 1 1�Y THE <br /> ACCURACY OF UTE INFORMATION. 111F U)CAL AGENCY IS RESPONSIBLE FOR IIIE COMPIH-nON OF 113E <br /> 'LOCA],AGENCY USE ONLY*INFORMA`nON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM 'B'(s)TO TI IE FOIJOWtNG ADDRESS. <br /> ,5rA:1E OF CALIFORNIA <br /> SfXrE WATER RESOURCES CON.I'ROL BOARD <br /> C/o S.W.17-EP.& <br /> DA'T'A PROCESSING CENTER <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 90723 <br />