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r� ��r, 'ti�..>.-;:«.:y�x:=--J- 1k �.�; as F= '� ea.-.o,���+,ri "'r•.y„�,�...;:�..._ „=.'`„L.•: a.,•�:'., ._� 't" .I <br /> A. <br /> .tit' <br /> INSTRUCTIONS FOR COMPLETING FORM"li" <br /> GENERA.INSTRUCTIONS s.' <br /> 1. One FORM"B"shall be completed for tank for all NEW' PERMU CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION,CFiANG$ <br /> 2. This form should be completed by either PEiAPPLI r the LOCAL AGENCY UNDERGROUND TANK <br /> TNSPECPOR r :., <br /> d Please type or print clearly all requested rntation. <br /> 4. Use a hard point writing instrument,you Making 3 cop' <br /> TOP OF FoRNE"MARK ONLY ONE ITEM" <br /> 1. Mark an((� the %ped to the ite best describes the ` the form is being completed. <br /> 2. Indicate th' !�lttltlwff name whe he-tank is installed. - `r <br /> L TANK DESCRIPW_1%4"ALL ITEMS - UNKNOWN-SO <br /> A. Indicate owners tank ID#-If there is nk number.that is .he owtiet�to identify the tank(ex.AB70789). <br /> B. Indicate the name of the company that factured the tank(, E TANK MFG.). <br /> C. Indicate the year the tank was installe x.19$7). <br /> D. Indicate the tank"capacity in gallons(ex.; or 10,000 etc) ry t <br /> Il. 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& D. ~ <br /> i 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 CA.S.#. (Chemical Abstract ce <br /> number),if box I is NOT checked in A. <br /> IEL TANK CONSTRUCTION-MARK ONE r119A ONLY IN BOX,A,B,C&,D <br />` Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 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.Ap comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVIVCIiO1V <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monito ' g requirements for the tank: <br /> VI.,INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE TIIE FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL.AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number,the, a digit jurisdiction <br /> number,the i it'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 /> IT IS THE itFSPONSIBTI.[TY OF THE LOCAL AGENCY THAT INSPFC3S TI-II?FACILITY TO VERITY THE <br /> ACCURACY OF THE INFORMATION. THE C:F ICY IS RESPONSIBLE FOR THE COMPLETION OF THE <br /> *LOCAL AGENCY USE ONLY Ti FOR FORWARDING FORM"A"AND ASSOCIATED <br /> FORM"B"(s)TO THE POLLOWIN D <br /> 'G r <br /> Sr OF " . , "f, Jool <br /> STATE WATER'UMURC ES CONTR DOARD 1 " <br /> a <br /> A DATA PROCESSING CENTER <br /> P.O.BOX SZ7 <br /> rr S1 fi D J rOUly� I . <br />