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,, E fR5 UC`TONS IML C OMPI.1 1 INCL FORM"IB" GENERAL INS717RUCDON& 1, One FORM"TB"shall be completed for each trial€for all NEW PERMnS,PERMIT C;I GFS, REMO AIS and/or any other TANK.INK)RMA110N C;IIANG 2. '. is form should be completed by either the PERmn'APPUCAN'Tor the L 6311 UNIHIRGROUND'IYANK INSPECIT)R- 3. Pleasetype or print clearly a31 requested information, 4. Use a hard point writing instrument.,you are making 3 copies. `IADP OF FORM-*MARK ONLY ONE TIEM' L Mark an (X)in the box next to the item that best describes the reason the form is being completed, 2. Indicate the I3I3A or Facility Hansa where the tank is installed.: I. TANK DF-SCRU-1-10N-C,0?4PI 13113 A11,rHIMS-III UNKNOWN-SCD SPM-111Y A. Indicate owners tank ZED#-If there is a tank number that is used by the owner to identify the tank(ex.,AE3707g9). II. Indicate the name of the company that:manufactured the tank(ex.ACME TANK MFG.). C. Indicate the year the tank was installed(ex. 1987), I.D. Indicate the tank capacity in gallons(ex.15,000 or 10,000 etc.),` TANK CPC} z .IS A. L. If MOTOR VEIIIC I,X1 FUEL,check box L and complete items CB&C. 2.If not MOTOR VEHICLE,DUEL,check the appropriate box in section A and complete items I3 &1.). EB. Check the appropriate box. C. Check the typeof IvIC)"f'OR VEHICLE FUEL(if box 1 is checked in A). D. Print the chemical sante of the hazardous substance stored in the tank and the C".A.S* (Chemical Abstract Ser ice number),if box 1 is NOT checked in A. IIIc TANK C OMTI."IZ.I;lC.10N-MARK ONE rl'FM ONLY IN BOX A,I3,C&I) 1. Check only one item inTYPE 01,S`,1311:31A9,'3'ANIC MATERIAL,RIAL INFERIOR LINING and CORROSION IpRC.D"IT"CTION. 2. If OTHER,print in the space;provided. 1"I". CI TNI?ORMA7170N L Circle A if above ground; circle U if underground;and circle broth if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3, indicate the T.LAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LMK ID X7IICDN 1. Indicate the LEAK DE rEC✓TIC)N system(s) used to comply with the monitoring requirements for the tank. 1. INFORMAMON ONTANK I'I3RMANl? I'LL SI?I D IN PI AC 11 L Eal'IMAI1;I DATE I.AS`I'IJS I3-MONI"TI/YER(January, 1988. or 02/88). 2. E.S CI ATE,ID QUANTITY of HAZARDOUS SU BS'I'ANC E remaining in the tank(in Gallons). :3. WAS TANK FILLED WITH IIv'I.KI'i I'F;R1AL? Check'Yes'or'NC)'. .AI"IBI.I '` N'1 MUST SIGN AND DA'I 3 I1IE IUR AS INI)m :.I7. IN'' UC'ITON IX)R 11IF LOCAL A ENC.'II8S The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number, The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421; The facility number must T)a the same as shown in form "A". Z'he tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave"it blank. I1'is Tula RI-NPC)NSIEBIT; OF I1IE LO A(UNCY°T'ID'E"[NSI ..1°S 111E FAC111rY TO II 111E ACCURACY OIVI1II3 INFORMA170N. 77,II1 LOCAL AGENC`Y IS RESPONSIBLE F()IC"I'III?COMP11HION OF 1 M— "LOCAL A614NCY r7SI3 ONLY*INFORMA711ON BOX ANT)1UR 117ORWARDING ONE "A"AND t`ASO CIAI1?I ISD *Ii"(s)IX)'11117,IsO WWING ADDR0SS. S'rA'I7F,OF CALIFORNIA SFA'I17 WkI'T:R RE:tr )UTB(7N Cx3N°`I701,BOAPJ) 6ATA PROC°E&SING CT I"I IC P.O.BOX 527