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IN';I'RUC11ONS FOR COMPLIHING FORM-Ir <br /> GENERAL IN'SYRUCIIONS. <br /> I. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGF.S, REMOVAI-S and/or any <br /> other TANK.INFORM)V11ON CHANGE <br /> 2. This form should be completed by either the PERMIT'APPUCANI'or the LOCAL AGI.N. CY UNDERGROUND TANK <br /> INSPECTOR. <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 TI'VM' <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form is being opmpleted. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK DESCRH`11ON-COMPIli-37E All,ITEMS-IIF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank TD #-If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <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.15,000 or 10,000 ctc.). <br /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEHIC1.13 FUEL, check box 1 and complete items B &C. <br /> 2. If not MOTOR VEHICIT"FUEL,check the appropriate box in section A and complete items B & 11 <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEAIICLE FUEL(if box is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number), if box 1. is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&1) <br /> 1- Check only one item in'TYPE OFSYSTEM,TANK MNIURIAL,INI'ERIOR LINING and CORROSION PROTECTION. <br /> 2. 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 0111ER, print in space provided. <br /> 3. Indicate the LEAK DETE(-nON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETEX,7110N <br /> 1. Indicate the LEAK DE�TEC`1710N system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENI'LY CLOSED IN PLACE <br /> 1. ESTIM/VIT.D DATE LAST"USED-MON71-II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT?ANITIMIAL? Check 'Yes'or'NO'. <br /> APPI10%Nf MUST SIGN AND DATI:?11113 FORM AS INDICAT Mi . <br /> INSTRUCTION FOR TIIE LOCAL AGENCIES <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 (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 RESPONSIBUITY OF 11113 IOCA L AGINCY THAT INSPEC.I.N11113,FAC]11X1`Y TO VERIFY 11117 <br /> AccuRAcy ownw INFORMAHON. ITIS LOCAL AGENCY IS RENPONSIBLE FOR THE COMPIE11ON ol-'n[E <br /> LOCAI,AGENCY USE ONLY'INFORMS110N BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIAIUD <br /> FORM'B'(s)IX)-ITIF FOLLOWING ADDRF-SS. <br /> STATF OF CALIFORNIA <br /> SLAlT WATI.3R RI,7,FA)U1Z(-rS CONI'ROL BOARD <br /> cpo sm.lu.l ns, <br /> DATA PROCESSING CI;XMIR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />