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INSTRUCTIONS FOR COMPLErINCC'-2 ORM"C3" <br /> GENERAL,IN'TRUC7TONS: <br /> 1_ One FORAM "B" shall be completed for each tank for all NEW PERMITS,PERMIT aTANGES, REMOVALS and/or any <br /> other TANK INFORMN11ON(:MANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the 1 )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 FORM:"MARK ONLY ONE TTI201- <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 DESCRIPTION-COMPLETI3 ALI.ITEMS-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.AB7078`1 <br /> 11 <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 /> 1I. TANK CONTENTS <br /> A. 1. If MOTOR VEIIICLF DUEL,check box t and complete items B&C. <br /> 2. If not MOTOR VEIIICLF ICEL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEIIIC:LE FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CN.A.S.#. (Chemical Abstract Service <br /> number), if.box 1 is N'OT checked in A. <br /> III. '.TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTTM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> 1V. 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 LFAK DET'E(-n ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI3'ITC TION <br /> 1. Indicate the LEAK DET'E(71710N systcm(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENII.Y CII)SED IN PLACE <br /> 1. ES'TIMNI`E) DATE I.AS`F USED-MONTII/YEAK(January, 1,988 or 01/88). <br /> 2. ES'TIMAT'ED QUANTTTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WHIT INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUS SIGN AND DATE 111E FORM AS I.NDICAILID. <br /> INSTRUCTION FOR TIIE 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. T'he 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 /> IT IS'IME RE.SPONSIBI111 Y OF TI3E1 I.ACAI.AGENCY THAT INSPI.CIS 11IE FACB,TIY 170 VERIFY 1111: <br /> ACCURACY OF T1IE INFORMATION. '11I1i IOCAL AGENCY IS RESPONSIBLE FOR'IIIE COMPLI'LION OF'IIIE <br /> "LOCAL,AG124(Y USE ONLY"INFORMATION BOX AND I4OR FORWARDING ONE FORM"A"AND ASSOCIA110 <br /> FORM"Ir(s)11)111E FOLLOWING ADDRESS. <br /> STNIIi OF CALIFORNIA <br /> STATEI WATER RESOURCES CONTROL BOARD <br /> C/O S.W.T.!Lt.P.S. <br /> DATA PROCT!SSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNI`,CA WM <br />