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I.NS,I'RUC;IIONS ICOR COMPT-VnNG FORM"B" <br /> GENERAL INSTRUCTIONS, <br /> I. One FORM"13"shall be completed for each tank for all NEW PERWI':%PPRAUr.(3#ANGES, REMOVAI.S and/or any <br /> other TANK TION CHANGE. <br /> 2. This form should be completed by either the PERMTr APPIICAN'T or the LOiCAL AGENff UNDERGROUND TANK <br /> INSP R. <br /> 3. Please type or print clearly all requested information. <br /> t. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM."MARK ONLY ONE n 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 DBA or Facility name where the tank is installed. <br /> I. TANK DFSCRIPI.ION-COMPI-MV,ALL TFEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) #-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. 10)87). <br /> D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br /> H. TANK CONTI?MJN A <br /> A. 1. If MOTOR VEHICLE;FCJEL,check box 1 and.complete items B&C. <br /> 2. If not MOTOR Vl3IIICLF FUEIL,,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 VEHICLE FUEL,(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank-an&the CA,S4.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. 'TANK CONSI'RUCTION-MARK ONE r11 M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTF,M,TANK MATERIAL, INTERIOR LINING and CORROSION PROTFCIION. <br /> 2. If O'T'HER,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 D T CHOLA sy-stem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DFt'ECRON <br /> 1. Indicate the LEAK DI7,['E("I"ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. IN17ORMAI ION ON TANK PERMANFNI7:Y 0 N)IN PLACE <br /> 1. FSI'IMATED DATE;I.AST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WTI'H INEKI'MATERIAL? Check'Yes'or'NO'. <br /> APPIICANT MUST SIGN AND DA1'F THE FORM AS ICA 'E9). <br /> INS17RUC11ON FOR 1111 LOCAL AG (CIES <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 IS THE RFSPONSIBHXI'Y OF THE LCKAL AGF.1`K;Y THAT INSPECTS IIIE FACII 1'IY'TO VERIFY THE <br /> ACCURACY OF TIH!INFORMATION. TME LO(11L AGENCY IS RFSPONSIBLE FOR TRIP COMPI1MON OF 11411 <br /> "IA)CAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND A.SSOaKrED <br /> FO -W(s)TO'IIIE FOI.1,OWING ADDRESS. <br /> S'TA'ID OF CAI/FORMA <br /> S1A'TE WAIDR RESOURCES CONIROL BOARD <br /> C/O S:W:EEP.S. <br /> DATA PROCESSING C'INI1R <br /> P.O. BOX 527 <br /> PARAMO'UN-l',CA 90723 <br />