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INSI-RUC17IONS POP,COMPLIA FORM*B1 <br /> .` One FO "13"shell lie completed for each tank for all NFEWPERMNN,P'RB II'CHANGES, OVALS andjor any <br /> other JAN <br /> K INPORMA110N C ANG <br /> _`Jbl'IRrtri shomd be completed by either the PFRAU.I'APPUCANT or the LOCAL,AC,IINCY UNDERGROUND TANK <br /> ENSPECMR. <br /> 3. Please type or print clearly all requested information. <br /> 4: Use a hard point writing;instrument,you are making 3 copies. <br /> I'OP OF M its ONLY ONE 1°IM <br /> 1. Mark an (X)in the box next to thee item that best describers the reason the form is being completed. <br /> 2. Indicate the DBA or facility name;where the tank is installed. <br /> 2. TANK I)I7`>` 1T() 113FI .I I"IE ICS UNKNOWN-So SIT Ply <br /> A. Indicate owners funk ID#..If there is a tank number that is used by the owner to identify the tank(ex. B70789). <br /> B. Indicate thenameof the company that manufactured the tank(ex.ACMETANY MI"G.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,fklf)or 10,000 etc.). <br /> 11. TANK CONITWIN <br /> A. 1. If m(YrOR VEMIC1,1 F'L1FL,check box 1 and complete items B&C. <br /> 2.If not MOTOR VETTIC7 E irOEL,check the appropriate box in section A and complete items B&T). <br /> B. Check the appropriate box. <br /> C. Check the type of N10TO VEHICLE FUEL(if box 1 is checked in A). <br /> D. Print the chemical narrate of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br /> number),if box I. is Nur chccked in A, <br /> HL TANK C O 7RUC;I ON-MARK ONE 171EIM ONLY K A,L3,C&I) <br /> 1.. Check only one item in 1-YPE"OF S STf> ,TANK NIA.'I'EWAL,INTEMIOR LINING and CORROSION PRO'ITC'ZION, <br /> 2. If OTHER,priest in the space provided. <br /> IV. ISI C2 INFORMN11ON <br /> 1. Circle A.if above ground; circle L.I if underg;r°oun 9 and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if 0`1'JER,print in space provided. <br /> 3. Indicate the LEtAK F F11 C FI0N system(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DE,1EX7110N <br /> 1. Indicate the LEAK DSII;C17IC) system(s)used to comply with the monitoring;requirements for the tank. <br /> VI. INIX)RMK13ON ON TANK PEIMANEN11M CLOSED IN PIAC,' <br /> 1. FSfIMA"1'ED DA'IT.' SI'CISBI)- OTNII"IIj"1'EAR(January, 1.91313€ix 0l.jAl3). <br /> 2. ESIIMATED OUA ITFY of HAZARDOUS SUBSUANCE remainin .in;the tank(in Gallons). <br /> 3. WASTANK,FILLED WrIll INEIKIF MA'IIvI2IAL? Check'Yes'or'NO'. <br /> * .<_ <br /> P1 " 'T MUSrSIGN AND D)VI"I3°III:?FOAM AS I I)I '[17D. <br /> INS`MUC170N FOR11111 LOCAL AClENC:IIk <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 salve as shown in form "A". 1he <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 /> Tr IS 17111 .,5 S"II3L XI'Y 0171111i LOQUAGENCYTILAT I SPW71 x"1HE FACILrry TO VERIFY JlUi <br /> ACCURACY OF'11W—INFORMNI10N. THE IX)CAL AGAI?. C 'IS 22ESRO SIBL F 1 )R 711II , PLILHON OF'1112, <br /> C <br /> AGE Y Lr "I O I I )R ON , D IX)2C ]FORWARDING ONP MRM"A"AND AS, s A X71) <br /> FORM'Fr(s)TO 111E FOILOWING ADDRKSS, <br /> HT1?Oil C&LUX)RNIA <br /> SrX <br /> LA <br /> L" A'I AIICC II2ClI.4 2) <br /> ' `/o&W.1,711ES.I I-., <br /> DATA PROC]M&SING CA; .1 R <br /> P.O.BOX 527 <br /> PA COLD,C°A.WM3 <br /> AOL <br /> z + <br />