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[N,�xRucl[70NS FOR COMPI.YXING Y'Okm'W
<br /> GENERAL IN9FRUCTIONS,
<br /> 1, One FOR.M "B"shall be completed for each tank for all NI.3W PERMI'IN, PERMIT'CHANGES, REMOVALS and/or any
<br /> otber'FANK INFORMKIION CAIANGE.
<br /> 1 This form should be completed by either the PERMIT APPLICANI'ar the 1,000.ACA NCY UNDERGR9JJND TANK
<br /> INSPEC70R.
<br /> 3. Please type or print clearly all requested information.
<br /> 4. Use a hard point wr�t instrument,yqu am making 3 copies,
<br /> '110P OF FORM:'MARK ONLY ONI!M7M
<br /> Mark ail (X)in,the bQx,ntW to the irc ir. chat best describes trQ ,ason the form is being completed.
<br /> Atdifatt the 1313A or'-PaNiisy name when, the tank is installed
<br /> L TANK DYW,R r'4ftdN1-' MmPtimls?Am rmw. IF UNKNOWN-S4*SPH133Y
<br /> A. Indicate o%,ners, tank ID # -If there is a tank number that is a,seJ by theowner to identify the tank(ex.AB70789).
<br /> B. Indicate the nan'xw-Q'f the company tha. m4nufactu red the tank o C.ACME'I'ANK M11G.).
<br /> C. Indicate the year the tank was installed 1987).
<br /> 1). Indicate the tank capacity in gallons(ex - ',000 or 10,000 ete) -
<br /> It. TANK CON'1TW, 1S
<br /> A. 1. If MOTOR VEIIICII.,' FUEL,check box 1 and complete items B&-C.
<br /> 2.If not MOTOR VI:',IJICLE FULL,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 VERICLE,MJEL(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.S4. (Chemical Abstract Service
<br /> number), if box 1 is NOT checked in X
<br /> 111. TANK CONSTRUC'T'ION-MARK ONE TIFM ONLY IN B6X A, 13,C&1)
<br /> 1. Check oniv one item in TYPE OfSYST7.-M,TANK MATERIAL,INTI:1UOR LINING and CORROSION PROTE(71'102.
<br /> 2. If OTIlf7k, 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 LEAK DY71-E(TpION system(s) used to comply with the monitoring requirement for the piping,
<br /> V. TANK Ll'!AK DUIT(717ION
<br /> 1. Indicate the LEAK DIH-I-EX-171ON system(s) used to comply with the monitoring requirements for the tank,
<br /> VL INFORMATION ON TANK PERMAN1.3,NILY CIA)SIF0 IN PLACE
<br /> 1. ESTIMAI'ED DXIT:LASTUSI.,'.D-MONrI1JJYEAR(January, 1988 or'01/,88).
<br /> 2. ESTIMATED.QUAINFITI'Yof IIAVARI)OUSSUIKS'I (:F:'
<br /> 'i\Nreniainingin'i�ic tank (in Gallons).
<br /> 3. WAS TANK FIT ED WITH INERT MA111"RIAL? Check 'Yes'or'NO'.
<br /> APPLICANT MUST SIGN AND DN1'F'11IR FORM AS INDT(W.110.
<br /> INSTRUCTION FOR T7 IE IX)CAL AG13WMN
<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 sjx digit tank number. The county and jurisdiction numbers- are predetermined and
<br /> can be obtained by calling the State Board 016)739-2421. The facility number must be the same as shown"in-form "A". 1'he
<br /> tank number may be assigned by the local agency, however,this number must be numerical and cannot coatain an alphabet. If
<br /> the local agency prefers- the State Board to assign the tank number,please leave it blank.
<br /> IT ISTITE RJ1,SPONSIRIIXI-f 01"ITIE3 LOCAL AGENCY 111ATINSPIX7113 FACTIffry. IM VERIFY171TE
<br /> ACCURACY 017'111E INFORM)VI1ON. 7111i LOCAL AGINCY IS RESK)NSIBIX.Iz()R'I1IE COMPLIAION OF 11IF
<br /> *1,OCAL AGIWCY US),ONLY'INFORMA711ON 130X AND FOR FORWARDING ONE FORM*A"AND ASSOCIN110
<br /> FORM-13"(s)TO 11M,FOLLOWING ADDRI.WL
<br /> STATE 017 CA11FORNIA
<br /> WA'11,"R R1,SOUR(77?5 COINWROI,BOARD
<br /> DNrA PROC11,SSING(-JWITlK
<br /> P.O.BOX 527
<br /> PARAMOUNI',CA 90723
<br />
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