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INSTRUCTIONS FOR COMPLEIING FORM"TI" <br /> GENERAL INS'I'RUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PF.RMT'I'S,PFRMI'T C'IIANGES, REMOVALS and/or any <br /> other'TANK INFORMA11ON CIIANU <br /> 2. This form should be completed by either the PERMIT'APP11C AN'I'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <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 I'I'IW" <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 /> 1. 'TANK DESCRIPITON-C OMPI UM4 All.1717EMS-IF UNKNOWN-SO SPIXIFY <br /> A. Indicate owners tank ID#W If there is a tank number that is used by the owner to identify the tank(ex,AI370789). <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 /> II. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE:FUEL,,check box 1 and complete items B &C. <br /> 2. If not MOTOR VEHICLE?FUEL,check the appropriate box in section A and complete items B & I). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICI.,E 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 /> HL TANK CONSTRUCTION-MARK ONE TI1?M ONLY IN BOX A,T3,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MAI MIAL,INIERIOR LINING and CORROSION PRO'l1:1VI'ION. <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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DLTF.CIION <br /> 1. Indicate the LPAK DE'l l' 711ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMA EN11Y 0A)SED IN PLAC13 <br /> 1. ESTIMATED DA1,17.LAST"USED-MONTII/Yl'sAR (January, 198£of 01/88). <br /> 2. E,,511MATED CZUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons), <br /> 3. WAS TANK FILLED WITH INERT'MA'117.R1AL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DX11,131I11 FORM AS TNDIC:AIVD. <br /> INSTRUCITON FOR 111.1?IA)CAL AGENCIES <br /> k <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 Stare Board to assign the tank number,please leave it blank. <br /> I'F IS 17-II:?RE.SPONS'IBI111.7Y OF'1141i LOCAL AGE.NC'Y 11INF INSPI?CI':i'IIIE FA(TLTIY TO VERIF°Y'ITIT? <br /> ACCURACY OP 11-IE INI ORMA1ION. TIIP LOCAL AGINC:Y IS RESPONSIBLE FOR 11113 COMPI..I:iIION OF 71111 <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND 14OR FORWARDING ONE FORM"A"AND ASS0)C1A113D <br /> FORM"I3"(s)TO I1-IE FOTI.OWING ADDRESS. <br /> STMT?OF CALIFORNIA <br /> STAIE WATER RESOURC IN C'ONIAOI.BOARD <br /> C/O S W.L'1?P.S. <br /> DATA PROCESSING CENTER <br /> 5 P.O.BOX 527 <br /> PARAMOUNT,CA 91)M <br /> i <br />