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<br />M'�WRU(TITONS 17OR COMPI Arc FORM 'B'
<br />CIEN.1 I" U£'1`fC N%-
<br />L One l ORIM 13" shall be completed for each task for all N1EW PERMMS, Pl..RmIs r 01,t4NGT , [FE-MC)R1A1 S and/car any
<br />otherTANK INFO tMA°PION C'IIANCslr
<br />2. 't his form should be completed by either the 1flRMT ` A C",A '1' or the L. O(AL ACE UNDE RGROUPWI)1 AN
<br />I I'Lr : 'OP—,
<br />3. Please type Or print clearly all re costed information,
<br />t'
<br />4. Use a haze poini writing i'nso-ument, .ou aremaking 3 topics.
<br />TOP OF I�C)ICM; *MARK 1.110NF LVW "
<br />1. Mark an, (�) in the box next to the item that best describes the reason the form is being completed.
<br />2. Indicate the I)I A,or P'; ility name where the tank is installed.
<br />x
<br />1. TANKDRSC ''110N - COMPLIN7 ALL TIMMS - IF UNKNOWN _ SO SYU a H1Y
<br />A. Indicate owners tank ITi # - It there is a tank number that is used by the owner to identify the tank (ex, Al370789).
<br />B. Indicate the mune oT'the company that manufactured the tank (ex. ACME TANK MFG.).
<br />C. Indicate the year the tank was installed (ex. 13$7),
<br />13. Indicate the tank capacity in gallons ('ex. r),(W or 10,0(X) etc.). :
<br />11. TANK (X) °t°[ bfr,I
<br />A. t.. If IvIC)TOR VEMIC l..i: FUEL, check box 1 and complete items B & C.,
<br />2. If not MCPTOR 6 EHIC1.,T, FUEL, check the appropriate box in section A and complete: sterns B & 1:).
<br />B. Check the appropriate box.
<br />C. Check the type of MOTOR Y1,1tICLE 1''iiEL (if boy :l is checked in A).
<br />D. Print the chemical narne of the hazardous substance stored in the tants and the C,A,S.#, (Chemical Abstract Se*ice
<br />number), if box 1 is %tE. T checked in A,
<br />III. TANK CC) S`3'12UC"1"IC) l a MARK C)N1 nvm, ONLY IN BOX, A, 13, C & 1)
<br />1. Check only one item in TYPF. OF SY s I'E,N-I, TAN7K ,,TE,I IAL, 1?N FERIOR LINING and CORROSION i'12(3'Z'IIC"i` ON,
<br />2. If OTHER, print in the space provided.
<br />IV. PIPING INFORMA'nON
<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)Is°I'BC'I'ION sys;tern(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LIM DL _X'I.°TC)
<br />Y®
<br />L ` Indicate the LEAK DFI'ECTION systern(s) used to comply with the monitoring requirements for the tank:
<br />VL 1NIk)RMA'n0N ON TANK PERMA EW11M CLOSED IN PLACE
<br />1. 05FIMA117,1) DATE, L,4,51' USED - MONTI'H/YEAR (January, 19,88 or 01/88), A
<br />2. i" FIMAI'I I) C)UANrifY' of ILAIfARDOUS SUBSTANCE remaining in the tank (in Gallons).
<br />3. WAS TANK E II,I i;I7 SSI' 'IT INI," '1' : 'IT RIAL.A:s Check 'Yes' or'% O',
<br />APPI1 i Jar SIGN AND DA1'E? `tits? FORM AS )I " . .
<br />11•I.. UC"1°10N FOR 71113 LOCAL AGE C'IRS
<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 Static Board (€316)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 Stage Board to assign the tank number, please leave it blank,
<br />rr IS um RESPONSIMIXrY 01r `IIID LDCAL AGENCY 111X1' 1 SPE (7.IN "17113 F{A.C:[I.I °1'0 VERIFY Y '11111
<br />A J C)le'I7IF3 X) A°I C3 . '17113 [ AL AGE NC -Y IS 1LINPONSIB1.13 FOR 1711:. (°C) IITI ON 01t I7I
<br />"LOCAL AGENCY USE. ONLY" F MA'110N BOX AND FOR R)1C A DING ONE. FILM A" AND A&SOCIXIMD
<br />FO 'B'(s) TO -I ICE.3 POI,1.C)WING ADDRESS.
<br />'KDVII? C)1r C'AE,1 iA
<br />15ATA PROC E—SSIN E C I '
<br />1'..034 BOX 527
<br />1`A C)t i i', CA 90723
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