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LM <br /> IN1S`.I.`RUC`I10NS FOR COMPLMING FORM'14' <br /> GENERAL INS`IRUCTIONS:- <br /> L One FORM "B"shall be completed for each tank for all NEW PERMYYS,PERMTF(MANGHS, REMOVAI-S and/or any <br /> other TANK INFORMA11ON CIJANGR <br /> 1 This form should be completed by either the PERWI'APHICANT or the LO(AI.AGENCY UNDERGROUND 1 N <br /> INSP W* ,.I*OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,ypu are makiAg 3 copies. <br /> TOPOF FORM wARK ONLY ow rn:I4- <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed- , <br /> 2. IndicatelM DBA or Facility name where the tank is installed. <br /> I. 'IANK DESCRWITON-,COMPIX M AIA.MIMS-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.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> 1). Indicate the tank capacity in gallons(ex.25,0M or 10,000 etc.). <br /> 11. 1ANK COMITTMS <br /> A. L If MOTOR VEHICLE FUEL,check box I and complete items B & C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items 13& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). <br /> 1). Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number),if box I is NOT checked in A. <br /> 111. TANK 0ONS-IRUCITON-MARK ONE,raw ONLY IN IM A,D,C& D <br /> 1. Check only one item in'TYPE OFSYSl'P,M,'I'ANKMAI'l.,.RIAL, INTITRIOR IJNJNG and CORROSION PROTF(-FTON, <br /> 2, If OTHER. print in the space provided. <br /> IV. PIPING INFORMXIION <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 I- ,AK DE'll"(71ON systcni(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK I.,EAK DUIMMON <br /> 1. Indicate the LEAK used to comply with the monitoring requirements for the tank. <br /> VL INFOR-MMION ON TANK PERMANENMY CIX)SIM IN PLACTi <br /> 1. E.911MA11.1) DNITI I.AS"I'USED-MONI1I/YE.MZ(January, 1988 or 01/88). <br /> 2. ES'I'MIXII-71)QUA; ITI'Y of HAZARDOUS SUBS'IAN(11,remaining in the tank(in Gallons). <br /> 1 WAS TANK F111.11.)wrm INEf(I'MATFRIAL? (..heck 'Yes'or'NO'. <br /> APP1JCANr MUST SIGN AND D/vninm FORM AS INDICXMD, <br /> INSTRUMON FOR'ITIF LOCAL AGFT4011: <br /> The-,late 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 1%,'V. The <br /> tank number may he 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 /> rr IS17M RESPONSIMIXI-Y OF 171E LO AI. I?A(,'IIYI'Y TO VERIFY111E <br /> ACCIJRACY OF111E INFOI(MNITON, TTIF 71A)CAL AGENCY IS RESPONSIB11?,FOR 1111:"COMPLE 1100 OF1711, <br /> 'LOCAL AGUNCY US141'ONLY'INFORNIMION MX AND FOR MRWARDING ONE FORM'A'AND AW3 )0YVI1,?D <br /> FORM TO DIE FOLLOWING ADDRE-S.S. <br /> STKI-E OF(-AIIIWNIA <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 9Tal <br />