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1NS1RUC`I1ONS POR COMPLETING 110 <br /> GENERAL INSTRUCiTONS: <br /> 1, One FORM"lY.Shall be completed for each tank for all NEW PERIVM' PERAUT CHANiGFS; REMOVALS and/or any <br /> other TANK INF ORMXIION CHANGE <br /> 2. This form should be completed by either,the PERM,rt APPLICANTor the LCXAL AGENCY UNDIxRGROUNII)TANK <br /> INSPECI'OR <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 nEm" <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 DESC:RIPITON-C OMPI.FrE ALL,TIT'S-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11)#-If there is a tank number that is used by the owner to identity 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. 1957). <br /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> U. TANK CONTIWIS <br /> A. 1. If MOTOR VEHICLE FUI:iL,check box 1 and complete items B&C. <br /> 2.If not MOTOR VI IIICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of M(,YI'OR 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 C.A:S.#.(Chemical Abstract Service <br /> number),if box 1'is NoT checked in A. <br /> III. 'TANK CONSTRUCTION-MARK ONE 1`11N ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OI'SYSTEM,TANK MA'I'ERIAI.., INTERIOR 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 01311,"R,print in space provided. <br /> 3. Indicate the LEAK DET'ECT'ION systems) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECI'1ON <br /> 1. Indicate the LEAK DL:1'EC:'IION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENI'I:Y CLOSED IN PLACE <br /> 1. ESTIMATED DNIF.'LAST USED-MONTTI/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMXIT D QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WI"lu INERTMATERIAL? Check'Yes'or'NO'. <br /> APPLICANr MUST SIGN AND DA71'U TIII?MRM AS INDICK119). <br /> INSTRUCTION POR 111E LOCAL AGENCIIAS <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 (91.6)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 /> rI'IS THF?RESPONSIBIIX[`Y OF THE LOCAL AGI?N('Y THX['INSPECTS I1IE FAC 11.1T TO VERIFY THE <br /> ACCURACY OF TIIF?INFORMA11ON. 111E IA)CAL AGENCY IS RESPONSIBLE FOR 1111:COMPLETION OF TIII <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC INMI) <br /> FORM"B"(s)TO 11II2,FOLLOWING ADDRESS. <br /> STA1E OF CALIFORNIA <br /> !;EKI3 WATER RESOURCES CONTROL BOARD <br /> C/O S.WT F.P.S. <br /> DATA PROCESSING C.LWf17ER <br /> P.O.BOX 527 <br /> PARAMOUNI`,CA 90723 <br />