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INSTRUCTIONS FOR COMPLETING 10!!1 s,B4=
<br /> GENERAL INSTRUCTTONS:
<br /> 1. One FORM t,` shall be completed for each tisk for all NEW PERMITS, PERMIT CHAMGES. REMOVALS and/or any
<br /> other TANK INFORMATION CHANGE.
<br /> 2. This s form should be completed by1 either the PERMIT APPLICANT or, the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR,
<br /> 3. Please type or-print clear 3 all ;e=<ted information,
<br /> 4. Use a harb point writing instrument, you ars making 3 coFry`s.
<br /> TOP OF FORM: 'MARK ONLY ONE ITEM''
<br /> 1, Mark a3 Xthe: s>v,. next to the item t hat E.,re;yt describes the r"E?csJn the form is being CC:,1E1pint,c'd
<br /> 2. Indicate the (iBA or Facility name Y,'h4're the tank is installed.
<br /> IA TANK DESCRIPTION - COMPLETE ALL 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 yank
<br /> (ex. AB70789) .
<br /> B. Indicate the nacre of the company that manufactured the tank (ex. ACME TANK MFG),
<br /> C. Indicate the year the tank was installed (ex. 987).
<br /> D. indicate the, tank capacity in gallons (ex. 25,000 or 10,000 etc.)
<br /> IIx TANK CONTENTS
<br /> IF MOTOR VEHICLE d. ,E , check box i and complete items B & C.
<br /> C. if not MOTOR ;uS:i ICL U L, check the appropriate box in section A and complete items B c&" D.
<br /> R. Check the appropriate box. 1
<br /> C. Check: Ci '}ty of M, 'Fri. !_i_ FUEL (if box 1 is r€hocked in A).
<br /> D. Print the chemical name of ie hazardous substance stored 1rr the tank and the C.A.S* C:1'.,t,lCal
<br /> Abstract, Service number),, i ( box _ is NOT checked in A,
<br /> IIIc TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & O
<br /> l . Check.only 3'yitem ;n TYPE
<br /> .G OF SYSTEM.
<br /> Y , ,F . t �A ' MR _, _�� , INTERIOR LINING
<br /> and CORROSION PROTECTION.
<br /> 2. if ODER. print in the space provided,
<br /> IVa PIPING INFORMATION
<br /> 1. Circle A if above t"7°".ound circle U if underground, And circle bo h if applicable,
<br /> ' If €Ah �;;;1circle: � ¢ OTHER, print t ;rl space provided
<br /> 3 indicate the LEAK DETECTION tem(s) used to comply with the monitoring requirement for the piping.
<br /> V. TAAK LEAK DETECTION
<br /> 1. ;.ndlt.,a:e the LEAK DETECTION system(s) used to comply with the monitoring requirements
<br /> euireiVent. for he tank,
<br /> VI. INFORMATION ON TANK. PERMANENTLY CLOSED IN PLACE
<br /> ESTIMATED DATE LAST USED D - MONTH/YEAR`=,fit (Janua Y. 1988 or 01/88)
<br /> 2. S �ATEDt €'il,fi`N ITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons),
<br /> u. WAS TANK FILLED WITH ,NERT Mr. Check `e orNO
<br /> APPLICANT MUST SIGR AND DATE THE FORM AS INDICATED.
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground storage t,
<br /> �� storage tank identification number is c:urrpr}<ed of the two digit county,Gy,rrurber, the three
<br /> digit jurisdiction number, the Six digit f; iliaty nt lber and the s:x digit tank number. The County and
<br /> jurisdiction number, are predetermined and can be obtained by calling the State Board (916) 227-4303. The
<br /> facility number, must be the same as shown in fDrm "A". The flank number may be assigned by the local agency,
<br /> however, this number must be nwarical and cannot contain an alphabet. If the local agency prefers the State
<br /> Board to assign the tank number, please leave itblank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> ANO FOR FORWARDING ONE FORM "A' AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING AGGRESS.
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