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fNS`I'RUC'ITONS 17OR COMPLLT17N6, FORM-Ir <br /> (iENERAi,msrRucnolsis- <br /> I, One FORM "B"shall be completed for each tank for all NEW PERNUrS,PT Rmrr(.71ANGF-S, REMOVAI-S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 1 This form should be completed by either the PERMrI'APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPWMR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a,hard point writing instrument;you are making 3 copies.- <br /> 1176P 66 FORM: 'MARK ONLY ONE'T.'1T;!M- <br /> 1. Mark an (X)in thc,box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBAjor Facility name where the tank is installed. <br /> 1. TANK DESCRII-17ION-COMPIla-B All,TIMMS-H?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.A1370789). <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 CONTENIN, <br /> A. I. If MOTOR VEHICLE FUEL,check box I and complete items B&C. <br /> 2. If not MOTOR VE411CLI3 FUEL,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 1 is NOT checked in A. <br /> III. TANK CON,1;I'RUCITON-MARK ONE 171-EM ONLY IN BOX A,B,C&1) <br /> 1. Check only one item inTYPE OF SYS'FEM,TANK MA'I'ERIAL, INFERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,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 O'ITIER,print in space provided. <br /> 3. Indicate the L1.,:AK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DET E('ITON <br /> L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMA'11;D DATE.LAST USED-MONrI'II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK WITIT INERT MATERIAL? Check'Yes'or'NO'. <br /> APHICAN'r MUST`SIGN AND DA"i'IIIE FORM AS INDICA11M). <br /> IN,'VMU(.'nON FOR'nIE IA)CAL AGINCIMS <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 inform "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 Is TnE RESTONS1131117rY 0171TIE LOCAL ACPI.NCY TIIK1ANSPE(.`I,%'I1IE FACI.I.XrYTO VERWY11111 <br /> ACCURACY OF'I71E INFORMYVIION. 'nlE I.,OCAL AGENCY IS FWSPONSIBLE FOR TIIE COMPLHIION 017'111E <br /> "LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCLIVIED <br /> FORM-Ir(s)TO 1II11.FOLLOWING ADDRF--,,-,. <br /> STATE OF CALIFORNIA <br /> S`FA'1 WA' <br /> .1. .1'ER RFSOURCP.S CONTROL BOARD <br /> C/O P.S. <br /> DATA PROCESSING CEXIM'R. <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />