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INSTRUCHONS FUR COMPLYNING FORM'Ir <br /> GENERAL,IN,%'IRUC711ON&- <br /> L One FORM 'B"shall be completed for each tank for all NEW PFRW. IN, PERMH'CIIANGES, RITMOVALSand/or any <br /> other TANK INFORMA7110N CIJANGR <br /> 1 This form should be completed by either the PEW'APPLICANT or the IDCAL AGI*W(-Y UNDERGROUNDTANK <br /> INSPIRT17OR- <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 IURM. "MARK ONLY ONE ril.m* <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 thi DFiA or Pacilit� name where the tank is installed. <br /> I. TANK DF-SC.RWITON-CO�JPIZFE AIJ,rl'EMS-If'UNKNOWN-SO SPF"FY <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.ACMI.1,TANK MF(.'i,). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex. T5,(X)0 or 10,000 etc.). <br /> 11. TANK(X)NIVNIN <br /> A. 1. If MOTOR VEHICLE FUF.L,check box I and complete items B& <br /> z <br /> 2. If not MOTOREVHICLE FUEL,check the appropriate box in section A and complete items 13& D. <br /> D. ('heck the appropriate box. <br /> C. Check the type of Iv1'OR 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 C.A,S.#. (Chemical Abstract Service <br /> number),if box 1.is No,r checked in A. <br /> 111. TANK CON'31RUCHON-MARK ONE IFM ONLY IN BOX A,D,C&D <br /> 1. Check only one item in TYPE OF SYS11,NC'PANIC NIATF,RIAL, INTERIOR LINING and ('ORROSION'PRO'1'1-,"(1110N. <br /> 1 If('DIET. print in the space provided. <br /> IV. PIPING INFORMIV11ON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK T)F,.rn­.(.-l10N system(s) used to comply with the monitoring requirement for the piping. <br /> V. 1`ANK IIAK D1r111C`I1ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with thL monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PERMANI:W17LY(11.)SID IN PIACI; <br /> I. ES-11MA11-D OAT]."IrASI'USED-NIONI'll/YEAR(,January, 1.988 or 01/88), <br /> 2. QUAN`l'lTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK PILLED WrIll INE'I;ff,%1ATF.RIAL? Check 'Yes'or'NO'. <br /> APPI,ICANr musr SIGN AM)DA'11i 11113 FORM AS INDI(WI11D, <br /> INS-I'RUCIION FOR 171F LOCAI,AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number, the ffircc 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 anal[ftibet. If <br /> the local agency prefers the State Board to assign the tank nurnber, please leave it blank. <br /> Iff IS'11ER Rf:.SPON,%Bllfl'Y OF*ITIE 1,OCAL AGE.NCymxr iNsmirn,"jin,FAcrury ix)w1'RH,*Y'1im <br /> AC(__TJRAC`Y OFTHE INFORM)VIION. '171E?r.00 AL AGENCY IS RESPONSIBLE FORTTIE COMPLENTON OF THE <br /> AGENC`Y USI`ONTM'INFORMAT10N BOX AND FOR FORWARDING ONE FORM'A'AND AW)CINIED <br /> FORM 711E FOLLOWING ADDRESS. <br /> 9DVJE OF CAIJFORNIA <br /> FUAIIEVAIER RUISOU W77P.S.COVIROT,W)A TIT) <br /> P.O.BOX 527 <br /> PARAMOUIVI',CA 9aal <br />