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INST'RUCHONS FOR COMPLETING A"B" is <br /> GENERAL INSTRU MOW <br /> 1. One FORM"I3"shall be completed for each tank for all NEW PERAMN PERMrT CHANGFA RP.MOVAI:S and/or any <br /> other TANK INFORMATION CHANGE. <br /> This form should be completed by either the PERMIT APPI C'.ANI'or the I. I.,AGENCY UNDERGROUND"TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly all recjuested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> "TOP OF W)RM;"MARK ONLY ONE rimes <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 DFSC:RIPITON-C OMP11TI`E Al-L rI`EMS-It?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.ACME'I'ANK MI'G.). <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 C:ONITMIS <br /> A. L If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 1 If not MOTOR VI:IIICI,E 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 I is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and-the CA,S.#.(Chemical Abstract Service <br /> number),if box 1. is NOT checked in A. <br /> M. TANK CONSTRUCTION-MARK ONE niw ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'I'ANK MATERIAL,, INTERIOR LINING and CORROSION PROTECIION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INII?ORMATION <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIEIZ,print in space provided. <br /> 3. Indicate the LEAK DMTX71ION sywtem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETF,CTTON <br /> L Indicate the LEAK DL7.' ,(-IION system(s) used to comply with the monitoring requirements for the tank. <br /> Vt. INF()RMAT[ON ON TANK PERMANEN'll-Y CLOSET)IN PLACI3 <br /> 1. I-SIIMATED DATE LAST USE[)-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMAT'EI)(ILANTI'IY of IIAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS"TAMC FILLED WII'I[INEKI'MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND Dt1 II?'IIIE?FORM AS INDIC NI ED. <br /> I.NSTRUCIION FOR IIIE 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 /> PT'IS TIIE RU,SPONSIBRZI'X OF THE W AL AGENCY THAI'INSPE0. ,i'IIIE FAC1LTff TO VERIFY TIIE <br /> ACCURACY OF`IIF;INFORMA ION. `IIE L(X AL.AGENCY IS RESPONSIBLE FOR niE COMPLETION OF nut <br /> •IA)C.AI.AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE IK)RM"A"AND ASSOCIATED <br /> FORM"B"(s)-11)'ITIE RX I.OWING ADDRESS. <br /> STATE OF CA:LWORNIA <br /> STATE WA:114,R RESOURCIS CONTROL BOARD <br /> C/o S.W-RE.P.& <br /> DATA PROCESSING CFNII?R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />