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�- g <br /> INSIRUC7.nONS IIOR COMI`1H17NG FORM'Ir <br /> GENERAL INSTRUCTIONS- <br /> 1, One FORM "B"shall be completed for each tank for all NEW PERM11S,PERMIT CTIANGF-S, REMOVAI-S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. '17his form should be completed by either the PERMIU'APPLICANI'or the LOCAL AGENCY UNDERGROUND'I'ANK <br /> INSPI"'OR- <br /> 3. Please type orprint clearly all requested information. <br /> 4. Use a bard point writing instrument,you are making 3 copies. <br /> Top oil Imm..*M AR k ONLY'6NE M!EM" <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,I)BA or Facility name where the tank is installed. <br /> 1. TANK DFSCRIP711ON,-COMPIZIM All,nl7EMS-WUNKNOWN-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.15,000 or 10,000 etc.). <br /> H. TANK CONIIININ <br /> A. 1- If MOTOR Vl--JIICII3 FUEL,check box 1 and complete items B &C. <br /> 2. If not MOTOR VEHIC1.1' FULL,check the appropriate box in section A and complete items B &1.). <br /> B. Check 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 CA.S.#. (Chemical Abstract Service <br /> number),if box I is NOT checked in A, <br /> III. TANK CONS1`RUCIION-MARK ONE nvm ONLY IN BOX A,13,C&1) <br /> 1. Check only one item in TYPE OFSYSTEM,`TANK MATERIAL, INFERIOR LINING and CORROSION PROTECTION. <br /> 1 If OTHER,print in the space provided. <br /> IV. PIPING IM?ORMNIION <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 Dt:I'E(.,-rION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLPIVX.'IION <br /> L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INIK)RMA'nON ON TANK PERMANEIVII.Y CLOSED IN PLACE <br /> 1. F-STIMA11,I) DATE I.Agl'USE'D-MONI'II/YEAR (January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIAZAI(DOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK i4m,f Im wri'li INERT MA'IMRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA11i'1111i MRM AS INDICATED. <br /> INS'MU(711ON FOR THE 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 /> rr ISTIIE RESPONSIBUM OF 171E LOCAL AGENCY 11INIANSIMN17117 FAC11,11T 1.1)VEIRIFY'nIE <br /> ACCURACY OF 111E INFORMATION. THE I.X)CAL AGENCY IS RESPONSIBLE FX)R 111E COMPLHIION OF 111E <br /> "LOCAL AGENCY USE ONLY"TNFORMNIION BOX AND FOR FORWARDING ONE FORM W AND ASSTS <br /> FORM'B'(s)-.110171.13 FOLLOWING ADDRESS. <br /> STA111 017 CALIFORNIA <br /> -AlT WNIT.R RE�VNJRCV-S C-0N.I'ROL BOARD <br /> C/o'S.W.au-ps, <br /> DATA PROCESSING CEIVIL41Z <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 90723 <br />