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INSTRUC11ONS MR COMPU117ING FORM'B*
<br /> 1. One ItOKNi'B"shall be completed for each tank for all NEW PERMM,P1 T(I GF , 1tFiN1C VA1 S and/or any
<br /> other TANK INFORMA170NC°1 NGR
<br /> 2. This farm should be completed by either the P RMri' PIS NI"or the O(AL AGiENCY UNDERGROUND'I"ANK
<br /> INSPECrOR.'
<br /> 1 Pleasetype or print clearly all requested information,
<br /> 4, Use a bard point. ruing instrument,you are making 3 copies,
<br /> TOP C)P 1rY ONLY E EW
<br /> 1. Mark an, )in the box next to the item that best describes the reason the form is teeing completed,
<br /> 2. Indicate t 1)Pcility name where the tank is installed.
<br /> 1. TAN .IY - •cbmmum AIS,rrms-IFUNKNOWN-SO sP.a -IFF
<br /> A. Indicate owners tank:Jp ,� f t4pre is a tank number that is used by the owner to identify the tank:(ex,A1370789):
<br /> 13. Indicate the nitrate of the�eompany'that manufactured the tank(ex.ACMETANK K MFG.).
<br /> C. Indicate the year the tank was installed(ex. 1987),
<br /> D. Indicate the tank capacity in:gallons (ex.25,OW or 10,000 etc.),'
<br /> 11. TANK CONrfENIN
<br /> A, 1, If MO`I'0R V IIIC L )= III.,,check box 1 area complete:items B d'c C.
<br /> 2.If not MOTOR VFIIIC".Lk FUEL,check the appropriate box, in section A and complete items B& 1:),
<br /> B. Check the appropriate box.
<br /> Cr. Check the type of MOTOR VEHICLE FUEL(if box I is checked in A). �
<br /> T), 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 /> 111. TANK CONSTRUCITON d MARK ONE rrFM ONLY IN BOX A,I3,C:&I)
<br /> 1. Check only one iters in'T`k Pig OF SYSI°E:TK TANX NCA'I'ERIAL,7N"I"ERTEN R LININCa and CORROSION I1E20Tl C.["lON.
<br /> 2. If OTHER,print in the space provided.
<br /> Ism PIIS. Cg INIAORMAITON
<br /> 1. Circle A if above ground,circle LI if underground,and circle;both if applicable.
<br /> 1 If UNKNOWN,circle, or if C)"1"F•TER,print in space provided.
<br /> 3. Indicate the I..I�.ALC ISCs"TEX.. ON system(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK I)L 1,C"1'It)IV
<br /> 1. `, Indicate the LEAK DP,,rECpI0N system(s)used to comply whh`the monitoring requirements for the tank.
<br /> VI. INIX)RMA'1710N ONTANK PLIC A Ea EIM SED IN PLACM
<br /> b
<br /> 1. ESTIMA"IT30 DA"TT T,AS"1'USED-PufC)INHI/Y., I (January, 1988 or Or/88).
<br /> 1 EgnMATED QUANrrrY of HAZARDOUS SUBS I'ANI C"F remaining in the tank(in(.3allons).
<br /> 3. WAS"PANIC FILL.,.D W11'JI I:VEwR`': `I`TRIAT:? Check 'Yes'or'NC)'.
<br /> APPLICANr MU5r SIGN AND E) ;'nIE3 FORM As . )ICA :.I).
<br /> ,.. LIC`ITC)N FOR IF LOCAL AGF C 1FS
<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 nurnbe.r. The county and jurisdiction numbers arepredetermined 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 contaih an alphabet. If
<br /> the local agency prefers the State Board to assign the tank number,please leave it blank,
<br /> "I'IS TUE RESPOMS1.1311117Y OFTHE LOCAL AGINCYnim,I SP 1'3 111H IrA.0".I:E 1 'I VEi 'Y"17IL
<br /> ACCURACY OF THE RMMI ON. ITIS LOCAL AGENCY IS RESPONSIBLE FOR TIII:I COMPLE1110N 017 11113,
<br /> "LOCAL AGENCY USE C)NLY'INIK)RMSITON BOX AND ItOR IX)RWARDING ONE 1$C) "A"AND AS.SC)C`. `1711)
<br /> IU -13"(s)TO-17113 FOLLOWING C3 I) S.S,
<br /> A"I73 OF CALIFORNIA
<br /> 'grN11Wr4°.1'TlR I2ES TTICC HS,C't) 1`I"I1t)L E3C)AI1I)
<br /> P.O.BOX 527,
<br /> PA OUNI',CA
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