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INITrRUC`110NS FOR COM11,131ING I* 'Ir
<br />GENIJ 4' RAL INSM.LIC7171ONS:
<br />L One FORM "B" shall be completed for each tank for all NEW PERMnN PERmn, CIJANGIIS, REMOVAIS and/or any
<br />other `PA IbIlk)MUION CIIAWsE
<br />1 'this form should be completed by either the PERNIT17APPLICAMF or the LOCAL AGENCY UNDERGROIJINIT)`TANK
<br />INSPEC'POR,
<br />1 Please type pe or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are making 3 copies.
<br />'I'OP OF FORM. 'MARK ONLY ONE F11IM'
<br />1, N-Pirk 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 />T. 'rANK DESCRIP110N - COMMEIE Aid, rnIMS - IF UNKNOWN - So SPIXm7y
<br />A, Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank (ex, AB70789).
<br />R Indicate the name of the company that manufactured the tank (ex. ACNIE'I'ANK MFG,).
<br />C. Indicate the year the tank %was instadled (ex. 1987)
<br />1), lndicaki, tine tank capawaym gallons (Cx, 215,00() or 10,000 etc,).
<br />H. 'JAN K CONIENrIN
<br />rh 1. 11'N'401"OR VE'llICLE FUEL, check box 1 and complete items 13 & C.
<br />2, If not yIO'I`ORVI J1.0 LE FUEL, check the appropriate box in section A and complete items B & D.
<br />B. Check The appropriate box,
<br />CCheck the type of M01'OR IM
<br />VEICILE %.'
<br />1F (if box I is checked in A),
<br />D, Print in-- chemical narne of the hazardous substance stored in the tank and the CA.S.#, (Chemical Abstract Service
<br />qumbcr)if box I is NO'I'clicckcd in A
<br />ITT, 'rANK CO1591RUC-11014 , MIARK ONE Yl -EM ONLY IN BOX A, B, C A D
<br />I. O
<br />Clhcck ordy on c ifxra in'f'YPE FSYS'T.I'M,'I`ANK MA]'F.RAL, IINJ'FRIOR LINING and CORROSION PR0'l`F(7I'I0N.
<br />2. If 0111EIR, print in that; space provided,
<br />TV. PIPING INFORMA'1101d
<br />1, Circle A if above groand; circle U if underground, an(] circle both if applicable,
<br />2. If UNKNOWN, cirde: orff 0-IIIEP, print in space provided,
<br />1 Indicate the LL`,AK DI"I need to comply with the monitoring requirement fi--)r the piping.
<br />V, 'rANK 1EAK DI-11'(717ON
<br />1, Indicate the used tocomplywnh the nronitoringrequirernerns for the tank.
<br />VT. INIA)MVIATION ONMANK'PERMANEXON CIXkSId3 IN PI CM
<br />1, E,',-H'IMA'FED DNI'
<br />b ' IAST USED - M0N7rIl/Y1`o\R (January, 1988 or 01/88),
<br />1 1-,S1'lN1zN'I'ED QUAN'B'FY of HAZARDOUS SUBSI'ANCE remaining in the tank (in Gallons).
<br />3, WAS 'I NK FILLI d-) Wl'I'l I INFRI' M,VrF.RIA L? Check 'Yes' or 'NO%
<br />APP11CANT SI' SIGN AND DNIV111E F()RM AS INDICNIT0,
<br />INSI'RU(711ON JX)R'1TIE I OCAL AGENC7IRS
<br />-Dw -rate underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction
<br />number, the six digso. facility munber and the six digit tank number. The county and jurisdiction numbers are predetermined and
<br />can be ohtained by calling the State Board (916)739-2421. 'Phe facility number must be the same as shown in form "A", 'Phe
<br />lack number may be aesi,pied by the local agency: however, this number must be numerical and cannot contain an alphabet. if
<br />the local avency prefers the State Board to assign the tank number, please leave it blanL
<br />a IS '17 If," R1,NPONSIBIT 1PY OR ',n III I,0CAL AGITNCY 'n IA`1' INSPIX71-zi, 171E FACI Lrry '110 VER11"i `nit
<br />ACC1 lILV7Y OF 17TEINFOR N&A'PION. '111E LOCAL A(3ENC`Y IS RESPONSIBLE FOR 17411 COMPLEFION OF 71,141T,
<br />'LOCA1, AGF.NCY USE ONLY' INFORMNI-ION IX)X AND FOR F()RWARDING ONE 17ORM *A' AND ASO CINIM0
<br />FORM -W(s)'1'0'IT1E RN1,0WING ADDRINS.
<br />,griVIE011 CA11FORNIA
<br />1I 'E WA`PITR RESOURCIN CO I' BOARD
<br />c/O S.Wj�znps.
<br />DA17A 11RUX-M&SING 0-,dS`17ER
<br />P.O. IX)X 5Z7
<br />P1Y1tAMOUNI7, CA 90723
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