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',WFIRUC31ONS F CrYMPLEXING W)RM'11'
<br /> GENERAL INS-FRUC'11OMS-
<br /> I -C'Ir"N(l
<br /> One FORNI "B"shall be cornplcicd for each taqk for all NUW PER PERMN
<br /> other'TANTY IM,URMWRON CHAINORL
<br /> 2, Phis form ;,`Tould be completcd by either the FFR I"APPLICANT or=he LOCAL AGNCS IJNDRG RIO-3,M) T',107K
<br /> INSPI t'('l`,0 F
<br /> 3, PIS is, ty'r- T print c1carlyall requested information.
<br /> J. Use to bavu, ,point writing instrument,you are making 3 copies,
<br /> TOP Olt FORM:'MARK ONLY ONE UEM'
<br /> 1. Mark an (XI, in the box next to the i;crn that best describes the reason the 'form is being complci,cd�
<br /> 2. Indicate the DBA oriFecility naive where the tank is installed.
<br /> 1, DItSCRIMION—COMP111,'FE All,TPU7,3S- 1"'UNKNOWN-SO S11m,11-ty
<br /> A. indicate uwners,tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.. AB7(r,89),
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACMF TANK
<br /> C. Indicate the year the tank was installed (ex. 1.987).
<br /> D, !nWicqic i-- iank capacity in gallons(ex.15,000 or 10,(1f3 etc.),
<br /> 11. TANK CONIVNI-S
<br /> A. 1, lfM0'1,`R VEHICLE FUE.I.,check box I and complete items B & C.
<br /> 2. It'not j,1,JTOR V1,111C11"FUFL,check the appropriate box in section A and complete items B A I),
<br /> R. Check the 3ppropriatc box.
<br /> C. Check the ivP e of MOTOR VEHICLE FUEL(if box I is checked in A.).
<br /> �
<br /> IS. Print the cbemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract SerN,-i"'c
<br /> number), if box I is NOT checked in A.
<br /> TANK CX)RURUICTITON-MARK ONE'I'l-EM ONLY IN BOX A, 13,C&1)
<br /> 1. Check ork"one item inTyPE 0l1SYSJT.,KTANK NIAITRIAL, INTERIOR ITNING and CORROSION
<br /> 2. If OTTJF ,. print in the space provided,
<br /> IV. PIPING 'ON
<br /> 1. CS; .Bove ground; circle U if underground„and circle both if applicable.
<br /> 2. if �L circle; or if 0'1'1132Rprint in space pro�,idcd,
<br /> I -ION,
<br /> 1 Indicate LEAK DI'lX,71 4ised to cornply%ith the monitoring requzi-emem for the pip;rg,
<br /> V. TANK LEAK DV17F7110N
<br /> ,i. Indicate H,,, l,EvkK used to comply with the monitoring,i-equirvivents fb! ahc talnk,
<br /> VT. INFORMA'11ON ON TANK P14"RMANINII.Y CLOSED IN PIACT,
<br /> I. uuIMA1) DA'117 I,\STUSI;D- '.,,40NTll/YI.AR (January, l9118 or 01/hs).
<br /> 2. E511MA S i.D 0UAN'I1TY of IMZARDOUS SUBSTANCE remaining in the tank (in CmIlon"').
<br /> 3. WAS TANK FILLFD WFFII INUITTMA11MIAL? Check 'Yes' or'NO'.
<br /> APPLICAN'll'MUST01(:IN AND DA11,1111E FORM AS INDIUVIV:1).
<br /> INSFRUICNION FDR 11ill LOCAL A(;T3N(117.S
<br /> '[lie state vt, i;Und storage tank identification number is composed of the. two digit county numh.cr. the three if
<br /> number, ft- J lit facility number and the six digit tank number. The county and jurisdiction numbers are and
<br /> can he obtaii+ by calling the State Board (916)739-2421. The facility number must be the same as shown in f'oi,m "A". P,:-
<br /> tank number niiy be assigned by the local agency-, however, this number must be numerical and cannot contain m alhi;k:"rtes, is
<br /> the local agency prefers the State Board to assign the tank number, please leave it blank.
<br /> rr IS'111F RI1.13PONSfRTl.r1'Y Of'11111 1.,OC_AL AGJENCY 111N1'INSPJ1(1N'l1TE FACRTI'Y'R.)VERIFY111F
<br /> ACCURACY OF 111F INFOR)V.110N. I'TIE LOCAL A(jl.,.N(Y IS RIJNff)NSIl3llt FOR1'1111COMPLUNION OFTTIE'
<br /> "L,0(_'AL AGLNCY USE ON Y"INFORMATION BOX AND FOR FORWARDING ONE 314ORM"A"AND A,�iSOCWIVD
<br /> PORM.-W(s) IX)111E KAIDWING ADDRUSS.
<br /> ST17SIV,OF(AJ IFORNIA
<br /> Sl'NIE WjVI1tR RE.�,�OLJRCVN(X)MYROL WARD,
<br /> C/o Sm.1"u-Ps.
<br /> DNI'A PROCE&SING UtNITR
<br /> CA SAM
<br /> 0 0
<br />
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