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INSTRUCTIONS FOR COMP1.L.110; DORM"I3" <br /> GENERAL INSI'RUCt'IONS: <br /> 1.. One FORM"B" shall be completed for each tank for all NEW Pf1RMrIN PERMIT CHANGI:'sS, REMOVAE.S and/or any <br /> other TANK INFORMATION CHANCL? <br /> 2. This form should be completed by either Ohe PE Yr APPI JCt1N'T or the LOCAL AGENCY 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 rl1..M' <br /> 1. 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 D0SMP'11ON-()OMPLEII?ALI,rT13MS-IF UNKNOWN-SO SP14nFY <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,OW or 10,000 ctc.). <br /> H. 'TANK C,ONIFNIN <br /> A. 1. If MOTOR VEIIIC:LI3 I UI I.,check box 1 and complete items B & C. <br /> 2.if. not MOTOR VEHICLI3 FUFL.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 VE1410 I FUEL,(if box.1. is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br /> number), if box'1 is NOT checked in A. <br /> III. TANK CX?NSTRUCTION-MARK ONE ITEM ONLY IN BOX.A,B,C&D <br /> 1. Check only one item in TYPE OF SYS'T'EM,'TANK 1YINITRIAL,IN ERIOR LINING and CORROSION PRanI ,.'CTION_ <br /> 2. If OTLLER,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 I FAK DE11ICTION systems)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETE(711ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENI7 Y C IA)SED IN PLACE <br /> 1. 1 STIMATTiD DATE I.AS'I'USED - MONrti,YI:AR(January, 198$or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA%ARI7OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INE RT MAIL RIAu Check 'Yes'or'NO'. <br /> APPLIC:AN1'MUSE'SIGN AND D)VIE711EI1 FORM AS INDIC:NII D. <br /> INS.CRUCIION FOR 1111H,L(X:1L 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 Sta*e Board to assign the tank number,please leave it blank. <br /> rI'IS'1IT1?RFSPONSIBII.rIY OF 1111?LOCAL AGENCY 1ITA7F INSPECIS 111E FACILPIY TO VERIFY'IYEI:i <br /> ACCURACY OF'IIIE INFORMA11ON. 'IIID LOCAL AGENCY IS RESPONSIBLE FOR 1IIE COMPITITON OF 11IE <br /> •I.O(:AL AGENCY USE ONLY"INFORMAIION BOX ANIS FOR FORWARDING ONE FORM"A"AND AS.SSOCINI'13D <br /> FORM"B"(s)TO TILE FOI.1 OWING ADDRESS. <br /> STAIV OF CAIIFORNIA <br /> i� FV%TE?WATER RESOURCES C.'ON17ROL BOARD <br /> C/O&Wnu P.S. <br /> DATA PROCESSING CENTER <br /> P.O.I3OX 527 <br /> PARAMOUNT,CA 90723 <br />