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--roll"I -1 <br /> IN91'RUC1IONSS FOR COMPIZIP VORM Or <br /> OFMIRAT.I&%11kUM1ON4S6 <br /> 1. One FORM'B"shall be completed for each tank for all NEW PURmus, PHRMrf CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APP11CAN.I'or the LOCAL 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 /> TOP Of'FORM:'MARK ONLY ONE 17.112W <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. TANK DIISCRIFIIION-COMPIZIM All.TURMS-IF UNKNOWN-SO SPIWAVY <br /> A. Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10.000 etc). <br /> M TANK CA)NI'FNI'S <br /> A. 1. If MOTOR VEIIICLF FUEL,check box I and complete iterns B& C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete itenisl B & 1). <br /> 13. Check the appropriate box. <br /> C. Check the type of MOTOR VE HIC1,14"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 I is NOT checked in A. <br /> 11.1. TANK CON,%'RUCIION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSFEM,TANK MATERIAL,WIURIOR LINING and CORROSION PROTIX711()N. <br /> 2. If OTIltill,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 OTHEA,print in space provided. <br /> 3. Indicate the LEAK DETI-101ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI!rF(7I1ON <br /> 1, Indicate the LEAK DIATrrION system(s) used to comply with the monitoring requirements for the tank, <br /> VL INFORMATION ON TANK PERMANINItY CIX)SED IN PIACH <br /> 1. ES`T7,%1.'f`I;D DATE' IA51'USED-MONTII/YFAR(January, 1988or01/88). <br /> 2. Eq'IMATVI)QUANZITI'Y of IIAIARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK 11LLED WITH INFRT MATERIAl,? Check 'Yes'or'NO'. <br /> APPucAmr MUST SIGN AND I)XI'13711111 FORM AS INDICATED. <br /> IN,1;TRUC11ON FOR 11111 IOC AL 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 /> rl'IS 11111 RESPONS11311117Y OF 1111?LOCAL AGENCY 1IIXI'INSPI:iC1N TlIF FACILITY TO VE-RIF"y <br /> ACCURACY OF 111E INFORM/VI1ON. 11111 LOCAL AGENCY IS RESPONSIBLE FOR'ITW_(X)MPIITIION OF TIIE <br /> *LOCAL AGENCY USE ONLY*INFORMNIION BOX AND I:UR FORWARDING ONE FORM *A"AND AW)CIN111) <br /> FORM FOI1.,OWING ADDRESS. <br /> STA7111 OF CALIFORNIA <br /> STATE WNFLIR REW)UR0LS CONTROL BOARD <br /> C/o&W.1-7L;P.S. <br /> DATA PROC13SSING CEN11iR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 901723 <br />