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r 4 <br /> INSTRUCTIONS FOR COMPI..LrTING FORM"II" <br /> GENERAL INSTRUCTIONS. <br /> L One FORNI"B"shat(be completed for each tank for all NI3W PERMITS,PuRM.IT C7IIANGES, REMOVAI S and/or any <br /> other TANK INFORMN11ON CIIANGE. <br /> 2. "Phis form should be completed by either the PERMIT APPLICANT or the I.X)C'.AL AGENCY UNDERGROUND TAl4K <br /> INSPECT I'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 ITEMI.. <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 tha I:)13A(Ir Facility name where the tank is installed. <br /> 1. TANK DESCRIPTION-C Y)MPLI:?IT3 All.ITEMS-IF UNKNOWN-SO SPECIFY . <br /> A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex. AB7f)7S <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 CONITWIS <br /> A. 1. If MOTOR VI IiICLE I`UE1L,check box 1. and complete items B&C. <br /> 2. If not MOTOR VEHICLE,FUF_L,check the appropriate box in section A and complete items I3 & D, <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 NOTchecked in A. <br /> III. ".TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYS'ITM,TANK MAITRIAL, INTERIOR LINING and CORROSION PROITC110N. <br /> 2. If OTIIER,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 I)EI'ECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DRIV.CTION <br /> 1. Indicate the LEAK DL I"EC"TION systcm(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANIMLY CTASM)IN PLACE? <br /> 1. ES"TIMATE"]:) DA'I;'E I..AST USED-MONTII/YF...AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IW_ARDOCJS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK TILLED WTTII INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPIJC:ANT MUST SIGN AND DATE 111E FORM AS INDICAIT0. <br /> INS'I'RUC.TION FOR TME IACAL AGENCII?S <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 (1316)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 /> 173'IS 71711E RESPONSIBI1.11'Y OF'ITIE LOCAL AGENCY THAT INSPIX.'I517IF FACILITY'TC)VERITY 7'11[3 <br /> ACCURACY Oil 71E INFORMATION. 'ITIS IXX'AL AGENCY IS RESPONSIBLE FOR'IIIE COMPLE110N OF ITIS <br /> "I.00AI.AGENCY"VSE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCINIT:0 <br /> FORM"B"(s)11)11111 FOLLOWING ADDRESS. <br /> STAI13 OF CAIJPORNIA <br /> S'A'IL WAII:?R RLSOURC BS C ONI'ROL BOARD <br /> C/O S.W.11 P.S i <br /> I)Nr.A PROCESSING CENTER <br /> P.O.I.30X 527 <br /> PARAMOUNT;CA 90M <br /> 0 <br />