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7 <br /> IMAU'RUC-11ONS IX)R COMPLLTITNG FORM*W <br /> GENERAL msixucnoms- <br /> I <br /> I. One FO M "B'shall be completed for each tank for all NEW PERMJIS,PERMIT(1 GPS, RUMOVAUS and/or any <br /> other TANK.INFO ZION CIIANGF_ <br /> 2. This form should be completed by either the PERMIT'APPLICANT"or the LOCAL AGEN(7Y UNDERGROUND)SANK <br /> INSPEC71'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 MW <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 DF-SCRIYJION-C()MPIla'E All,ITEMS-111'UNKNOWN­SO SPECIFY <br /> A. Indicate owners tank ID #-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. 1987). <br /> D. Indicate the tank capacity in gallons (ex. 2.5,000 or 10,000 etc.). <br /> H. TANK(X)NrEN`fS <br /> A. I. If MOTOR VEHICLE FUEL,check box 1 and complete items 13 & C. <br /> 2. If not MOTOR VEHICLF"FUEL,check the appropriate box in section A and complete items B & 17. <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 and the C.A,S.#. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> 111. TANK CONS`.I'RUC'I1ON-MARK ONE'rI`EM ONLY IN BOX 13,C&1) <br /> 1. Check only one item in TYPE OF SYSTEM.TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA17ION <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 DETEtAlON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEMIT.Y CIA)SED IN PLACE <br /> 1. ESTIMATED DATE I.A'51'USED-MONFII/YEAR (January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK Faim WITH INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MU,Vr SIGN AND DATE'nIE FORM AS tNDICA17ED. <br /> IN4;'MU(.'IION FOR THE LOCAL AGENCIES <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 /> ri,is THE RF-woNsunilw ownw LOCAL AGENCY TTIKI'INSPM.*,S'IIIE FACII.Xff TO VERIff, '11111i <br /> ACCURACY OIVIIIE INFORMA'ITON. 771F LOCAL AGENC'Y IS RESPONSIBLE FOR IIIE(X)MPI.HIION OF'11IE <br /> "LOCAL AGENC-Y USE ONLY"INFORMATION BOX AND MR FORWARDING ONE FORM*A"AND A!%OCIA`1`ED <br /> FORM'B'(s)1`011111 FOLLOWING ADDRESS. <br /> `;FATV 017 CALIFORNIA <br /> STNIT" <br /> WATER RI )URCF-S CONI 01,BOARD <br /> C/o S.W.11,111P.I& <br /> DATA PRO(MSSING (1WIMR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />