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I 71W
<br /> TNS1'RUC'11ONS FOR C(.)MPIJLING FORM-li-
<br /> GFNERAL INSI'RU(7110NS:-
<br /> I
<br /> I. One FORM "B" shall be completed for each tank for all NEW PFRmus,PI RMI7r CHANGES, REMOVALS ind/or anv
<br /> other TANK INFORMATION CIIANGE
<br /> 1 111is form should be completed by either the I'ERM17I'APPI1C-4XI7 or the LO(AI,AGENCY UNDERGROUND'I'ANK
<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 1`11T.M'
<br /> 1. Mirk 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 Facilitv name where the tank is installed,
<br /> I. 'TANK DF-SCRHYFION-COMPTIE11F ALL rI'EMS-IF UNKNOWN-SoSPECjFy
<br /> A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank (ex.A1370799).
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACME'TANK MF(.i,).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> 1). Indicate the tank capacity in gallons(ex.25,000 or:10,000 etc.).*
<br /> 11. 'TANK(X)NI1:NI',%
<br /> A. L If MOTOR VEHICLE,FUEI.,check box I and complete items B& C.
<br /> 2. If not M0'I'0R VEHICLE FUFL.check the appropriate box in section A and complete items 11& 1).
<br /> B. Check the appropriate box.
<br /> C. Check the type of%10'1'(.)R VETIICLE FUFA,(if box I is checked in A).
<br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (C.hemical Abstract Service
<br /> number), if box 1.is N01'checked in A.
<br /> IM 'IANK CONS-17RUC11ON-MARK ONEI T.ITW ONLY IN IX)X A,D,C,&D
<br /> I. (,'heck only one item in'rYTIE INTERIOR LINING and CORROSION
<br /> 2. If O'rIIER, print in the space provided.
<br /> TV. 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 0111ER, print in space provided.
<br /> 3. Indicate the LEAK DITIE(7110N sy%tern(s) used to comply with the monitoring requirement for the piping,
<br /> V. 'TANK IJAK DI3rITX-'I1ON
<br /> 1. . Indicate the LEAK DE-I'T.,C'FION System(s) used to cornpJyArhh the monitoring requirements for the tank.
<br /> V1. INFORMA"ON ON 17ANK PE.RMANENI'LY CLOSED IN PLACI?
<br /> I. ES71IMN1131) DA'11:'.I.-ASI'USI-D-MO\-1-11/YI'AR(january, 1.988 or 01/89).
<br /> 2. E-51IMi1FED Q1 IAN'1117Y of HAZARDOUS SUBSI.'ANCE remaining in the tank- (in Gallons),
<br /> 1 WAS TANK FII.J.,ED wrm INERl'MAI'F.RIAL? Check 'Yes'or'NO'.
<br /> APPI,I(:ANI'MUST SIGN ANT)DX11i 111111 FORM AS INDICX111D.
<br /> INSIRUC17ON FOR 311E LO(Al,
<br /> The state under-round 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 ?'ik". I'he
<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 Slate Board to assign the tank number, please leave it blank.
<br /> ffIS'11113,RESPONSIBUXIN OF'1711;IOCAJ,AGENCY'I1IX1'INSPIX,'IS 1111 FACIL,TIY TO VI,RII7y'IjTI?
<br /> ACCURACY OF171TE INFORMN1710M 711E?-OCAL AGENCY IS RE-SPONSIBIE FOR'17JE COMPIXr110N OF 17111
<br /> 'LOCAL AGEN(Y USE ONLY'INFORMA711ON W-)X ANT)FOR FORWARDING ONE FORM 'A'AND ASSOCl/vIED
<br /> X)RM 'B'(s)TO 71111i FOLLOWING ADDRESS.
<br /> SIWIT-,OF(ALIFORNIA
<br /> FI'X.11!WXR:sR RFV01,jJPtf7,S(Y)NMROT, W)AMt,
<br /> DA:1A.PROCESSING 0,,N`�-R,
<br /> P.O.BOX 527
<br /> PARAMOIJN`17,CA 9W11
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