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INSTRUCTTONS FOR COMPI.IMNG I "B" • <br /> GENERAL INSTRU(TIONS: <br /> 1. . One FORM"I3"shall be completed for each tank for all NEW PERMPIS,PERMrT CI hNGI?S REMOVAIS and/or any <br /> other TANK INFORMATTON CTIANGE. <br /> 2. This form should be completed by either the PERMPr APPI iCANr or the [.)CAL 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 IN)RM 'MARK ONLY.ONE.ram- <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 /> I. 'TANK DFSC.'RIVIION-C'OMPLI-7173 ALL TI VMS-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 /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. TANK CONT13NIN <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VI:IIIICL,E FUEL,check the appropriate box in section A and complete items B& D. <br /> B. Cheek the appropriate box. <br /> C. Check the type of MOTOR VEHICLE 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 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK.ONE 1711W ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE.OF SYSTEM,"TANK MATERIAL,, IN'F'ERIOR LINING and CORROSION PROTECITON.. <br /> 2. If OTITER 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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DE'I'FC'I'ION sy-,tem(s) used to comply with,the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETEC711ON systems) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANEM17 Y CLOSM)IN PLACE <br /> 1. ESTIMATED DATE LAST USED- MONTH/YFAR(January; 1988 or 01/88). <br /> 2. ESTIMA`IEI)QUANTFI:Y of HAZARDOUS SUBSI'ANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WTI'H INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPI1CANr MUST SIGN AND DA'I'S T'FIE FORM AS INDICNIM. <br /> INSTRUCITON FOR'IIIL LOCAL 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 /> rT IS THE RFSPONSIBIIX"OF TTIE LOCAL AGENCY THAT INSPE(',Ifi TTIE FACILrrY'I'O VERIFY TIIE <br /> ACCURACY OF 1I1E INt?ORMATTON. '171E LOCAL.AGENCY IS RESPONSIBLE FOR TTIE COMPIJtMON OF flu! <br /> 'LOC/d,AGENCY USE ONLY"INF ORMA'111ON BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FO 'B'(s)TO 1I1E POI.J,OWING ADDRESS. <br /> STAT': OF CALIFORNIA <br /> STATE WI IMR RESOURCES CONI'ROL BOARD <br /> C/O S.W.E EP_S. <br /> DATA PRCK'ES.SING C FFER <br /> P.O.BOX 527 <br /> PARAMOUNr,CA 90723 <br />