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<br /> INSTRUCTIONS FOR COMPLETING FORM "B'`
<br /> GENERAL INSTRUCTW4:,.,. s .,-,
<br /> s a "'
<br /> l Chr Fc R;' E3 ,11 I-r t m: : t. . e�ch ank for a.11,,l• PERMITS PERMIT CHANGES, REMOVALS and/or any
<br /> other TANK INFORMATION CHANGE ` ' =
<br /> 2-, Tti s ff r'rr' ..houtd.be c ornpletod hy either the PERMIT.*LICWr,'br the'LOCAL:AGENCY UNDERGROUND TANK
<br /> INSPECTOR.
<br /> ;s Pled,_ ty,.. .r p: ins clearly al i requested in:ormatiiori
<br />' 4 Ilse-a bard point wr^t i'ng instrument. you are making. 3 cies.
<br /> TOP OF"FORMT _n;MARK ONLY ONE ITEM" .... .
<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,-rani l it y namr� where the iwank is installed.
<br /> I". TANK DESCRIPTION' - COMPLETE ALL ITEMS IF. UNKNOWN, -� SO, SPECIry
<br /> A. irlul dt:,' cwrer'j to r, .Ii) If tl" c' is a t-an'r: number that is• usediby,the owner to identify the-bank
<br /> R indicate the;nam:e of the company that manufae,tured the tank (ex ACME. TANK MFG),
<br /> C. Indicate the year the tank was
<br /> ✓i. Indicate the tank cap: :i y it aal'ons (ex. 25.GOO or 10.001);gtC
<br /> I1 . TANK CONTENTS _
<br /> .iii. - -
<br /> A 1. 11 'MOTOR VE:HICI':C FLiFL.. rheck box I and complete fteM2 B'& G. ..
<br /> 2.._ If not MOT!33ULH10 '. I UEI., check t.h: appropriate box in section A and c'omplRte items B & D.
<br /> Ei Check the appropri<itej box. _
<br /> E . Check' +he type of MOTOR VEH I CI E F UI I (if' bux,,1 is chE?Ckesf� A).
<br /> D Pr'int,,th idtii:mic.al name of the hazardous stibst'dnce stared=•in the tank and the C,A.S* (Chemical'
<br /> Abs, ,rac:t. Service number ), if tn;,x 1. is Ny)[ checkod .in A
<br /> III . TANK CONSTRUCTION MARK ONE ITEM ONLY-IN BOX ., C & D
<br /> 1. Check or'Y- one`item i1.1 ;l, TM. TANK MATERIAL`, T'NT RIOR LMI-NG�'and CORROSION PROTECTION
<br /> 2, If 0.HFR. print in the space prnvided: _._ 49 �,f•,
<br /> IV. PIPING INFORMATION
<br /> r T. Circle A if abaVe ground circle U if underground, and Circle both, If a livable.
<br /> 2 ...,If.UNKNOWNN 'circle.; or.-1f OTHER, print in space. proylde�
<br /> 3. Indicate the. LEAK DETECTION systems) used to.comply with-the monitoring; requirement for the .piping.
<br /> V. TANK LEAK -DETECTION
<br /> X: Indicate the LEAK DETECTION system(s) used to 'comply'wi.th t .;,moni.toring requirements for the tank.
<br /> VI. INFOPAATION ON ;TANK PERMANENTLY CLOSED IN PLACE '. .
<br /> ESTIMATED DATE LAST USED M0114 HIYEA.R {,];anuary. 1988 or..01/88)
<br /> 2. ESTt�ATF.D 00PNTITY of HAZARDOUS SUBSTA Ct remaining iri,'the tank (i"n QTlons).
<br /> 3., WAS, TANK . LIED WITH INERT Ma; 1:1AL"? Crte.ck 'Yes.. or .NQ'
<br /> APPLICANT MUST g"�N. AND DATE THE FORM AS INDICATED:
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The state underground �storaq:t4nk identification number is coraposW fAbe,two digit°cbunty number, the three.
<br /> digit Jura-sdi-ction number, t=Yie six dint facility number and the i> -c#i i-t tank -nurser. The county and
<br /> juri;Sdicttoh numbersi..are_prledetermirie(I and cat, be obtained by cal irr the.Stre.Boaid (916) 227-4303- The
<br /> facility number mu`t- be the -same as shown jr. form "A-"'. The tartk alb er:foray'be assigned-by the l ogal.,4gency:
<br /> howevdr, this number must be numerical and cannot contain an alpl'tabet, If:the 16pil agency prefers the Mate
<br /> Board `to assign the,tank number. please leave it blank. _- .. "s-
<br /> IT -IS THE 'RESPONSIBILITY OFJHE LOCAL AGENCY T440 INSPECTS,V TY 70 VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETIE DF:ME "LOCAL AGENCY USE ONLY" INFORMATION BOX
<br /> AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO T 'FOLLOWING ADDRESS.
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