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INSTRUCTIONS FOR B
<br /> GENERAL AL iNSTliU . .ONS:
<br /> l one , b Po h tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any
<br /> form;�, ,,.,w Mplatnt . : 01thar thv PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> <
<br /> y all requested Abrination.
<br /> 4 Use, a hard point writirg insirumorr, you are making 3 copies.
<br /> TOP OF FORM. 'MARK ONLY ONE ITEM" �
<br /> 1 Mark an (X) in the o tlejL !n the item that best describes the reason the form is being completed.
<br /> 2 indicate t
<br /> rx tzhe DBA of fa ' l ity Yamo where tP ' tank ,Stnctrli
<br /> ed
<br /> 1 . TANK DESCRIPTION COM€ L T E ALL ITEMS - IF UNKNOWN a SO SPECIFY
<br /> ,i-. .av U.'af„ Val K 1 P if to w in a zark nimbur t1{ t is used by the owner to identify the tank
<br /> i
<br /> K. n
<br /> �. ., n, + �' c tt t TANK MFG),
<br /> .
<br /> tip year t10 tart Wlk jrQjiej QX, 1987)
<br /> D !-Minoru the tank p
<br /> 11 . TANK CONTENTS
<br /> A 1.. if MPTOR VTHICIF FUTL,, the g box 1 and complete items B & C.
<br /> 2. 1i nut M07A 0!Ffj F h itl �iieti:k t,ho apfwopriate box in section A and complete items B & D,
<br /> B Clark the allroprive box,.
<br /> C Check Itm tvrT of M01011 VIHIClc fall [, (if h:�x, is checked in A).
<br /> Print the (`17E mica l �f the hazardous iu ` r s � �� '. a �
<br /> Ei t.<, tr,,. tt�,r�t r, { - ,�,u>t,�nt�.c st:rrtici lrl the tank and the�'C.A.S,��. (Chemical
<br /> Abel ”t L �o-?C4°ice r�alTll)or), i P FKA 1 is N01 checked in -A,
<br /> III . TANK CONST=RUCTION - MARK ONE ITEM' ONLY IN BOX A, B, C & D
<br /> 1 Check oxr> E,cTin r� 1 � 1ANK Mat', .A! . INTERIOR LINING �iCCORROSION OSION PRCrtCTTON
<br /> .
<br /> IV, PIPING INFORMATION
<br /> 1 Circle A if above ground circle a if underground, and circle both if applicable.
<br /> 2. If UNKNOWN .circle: or if OTHER, print t in space provided
<br /> 3 Indicate the LEAK DETECTION te0s) used to curtly with the monitoring requirement for the piping.
<br /> V. TAIK :LEAK DETECTION
<br /> 1 . Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. 1�
<br /> VIP INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE
<br /> 1. 4F ..& . t Z Z /_,.Xi
<br /> USED ra,tir i_ < ?tt;. .tary< 1988 or ii S.If t,1i'Si . .,
<br /> P. ESTPOTED 0ANT17Y f HAZARDOUS SURSIANCE in the tank (in int} Gallons)
<br /> p pppp � a
<br /> c� 4�!°�l � ,Niw . li §YI 1` ..�(t K; Check '�..`.� Vr ,Nl1
<br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED,
<br /> INSTRUCTION FOR THE LOCA. A&ENCIES
<br /> l e state underground storage tank identification f^,,'"ber is composed of the two digit county number, the three
<br /> digit u i soli ,. m number, the six ai 1 facility numbertwr and t4;,, s{x digittank number, The county.:and
<br /> jurisdiction r ,mbe i OR - OdUter rir i ned and can be obtained by calling the State Board (916) 227-4303. the
<br /> fac.i'ity numlier must. .-)e the same as shown in form ,'x" The tank number.may be assigned by the local agency,
<br /> however thisaumbet must, its numerical and cannot con a,ri lan 4 J ohabet. If the l oc I agency prefers the State
<br /> Board 'to a sign,4 hl tank number. p l e,as ham; it bl..0. °
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT ASPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFQRMATION, "ill. LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE LOCAL AGENCY USE ONLY- INFORMATION BOX
<br /> ANO FOR FORWARDING ONE FORM AND A SOCIATEDJO M "B"(s) TO ThE FOLLOWING ADCRESS,
<br />
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