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INS3RUCIIONS FOR C OMPLI-F1'ING FORM'IV <br /> GENERAL INS RUCIIONS- <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMM_,PE CI-JANcMS, REMOVAIS and/or any <br /> other TANK INFO TION CIIANGE <br /> 2, This form should be completed by either the PERMrl'APPLICANI'or the LOCAL AGENCY UNDFIRGROUNDTANK <br /> INSPECfOR. <br /> 1, Please type or print clearly all requested information. <br /> Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM� 'MARK ONLY ONE rrFM' <br /> L Mark 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 Facility name where the tank is installed. <br /> 1. TANK DF—SCRIP11ON-COMPIln'Ll All.ITEMS-IF UNKNOWN_,1X)SPEC H1Y <br /> A. Indicate owners tank ID # -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. 25,000 or 10,000 etc.). <br /> IL TANK CONITFNr,% <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 /> B. Check the appropriate box. <br /> C Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). <br /> 11 Print the chemical name of the hazardous substance stored in the tank and the C.A.S4. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> (_xJN,1;FRU(71`1ON-MARK ONE rJIM ONLY INBOX A,B,C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR IANING and CORROSION PROTECTION. <br /> 1 If OTHER,print in the space provided, <br /> TV. PIPING INFORMNI]ON <br /> 1. Circle A if above ground; circle U if underground.and circle both if applicable. <br /> 1 If UNKNOWN,circle; or if 011111K print in space provided. <br /> 1 Indicate the LEAK DETE"C'FION system(s)used to comply with the monitoring requirement for the piping. <br /> V TANK <br /> -J1?AK <br /> 1, lndic:ilc the LEAK DE-I'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMA711ON ON TANK PERMANENTLY C1,OSE-D IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTI711/YEAR(January, 1988 or 01/88), <br /> 2. FSI'IMKI'ED QUANITFY of MZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERTMA'I`ERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICXJJU). <br /> IN91'RUC'nON FORT 11E LOCAL AGENCFES <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 &-)ard to assign the tank number,please leave it blank. <br /> FT ISTFT;RUSPONSEBILTFY OF ITTE LOCAL AGENCY MAT mspWis ulE IzAcanY,ro VF Ynu <br /> RH, 1 <br /> ACCURACY OF 171E INFORMATION. IME,LOCAL AGENCY IS RESPONSIBLE FOR 111E COMPII.qTON OF 11113 <br /> "LO(AI,AGENCY USE ONLY'INFORMATI[ON BOX AND FOR FORWARDING ONE FORM*A*AND AW)CINFE:D <br /> F'ORM'11'(s)-1-0 11M FOIl.,OWJNG ADDRKS& <br /> S-l'A'[1,'0F CALIFORNIA <br /> Si A;1. W41VIR RT*,S()1JRCFS CONIROL BOARD <br /> - S- <br /> DATA PROCT*>0NG CEN`1`FR <br /> PJ W. ROX 577 <br /> PARAMOUINT,CA 90M <br />