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INSTRUMIONS FOR COMPLETITNG,FORM-Ir <br /> GENERAL INSMUcnow- <br /> I. One FOKM "B"shall be completed for each tank for all NEW PERAMN� PERMIT CHANGES, R[NOVALS and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2. This form should be completed by either the PEMM'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC170R. <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 TnW' <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 DESCRVITON-COMPIEIM All,1`17IMS-IF UNKNOWN-SO SPEC][FY <br /> A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tank(ex.AB70799). <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 /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> II. TANK CDNIFWIN <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 /> 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 I is NOT checked in A. <br /> Ill. TANK CONSMUC711ON-MARK ONE rM.M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE, OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTIIER,print in the space provided. <br /> IV. PIPING INFORMS11ON <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 DETEC17ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK MAK DUMMON <br /> 1. Indicate the LEAK DI TECIJON sy-tem(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CI,0SED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONI`11[YEAR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA7ARDOUS SUBSFANCE remaining in the tank(in Gallons), <br /> 3. WAS TANK FILLED Wrlll INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DAVIT;THE FORM AS INDICK110. <br /> IMITMUMON FOR TTIE LOCAL 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 State Board to assign the tank number,please leave it blank. <br /> Yr is nm RESPONSIBILITY OF THE LOCAL AGENCY THAT l?4SPFC`I'S nIE FACILITY TO VERIFY TIM <br /> ACCURACY OF'nlH INFORMATION. 111111-A)CAL AGENCY IS RESPONSIBLE.MR 1171112,COMPLEMON OF 171H <br /> '11)CAL AGI NCY USE ONLY'INFORMA711ON BOX AND MR FORWARDING ONE FORM*A7 AND ASSOCIA17ED <br /> FORM'Ir(s)TO ME FOLLOWING ADDRESS. <br /> SMV111 OF CALIFORNIA <br /> STATI?WMEM RFSOURCIN. COMMOL BOARD <br /> C/o Smxmrs. ' <br /> DATA PROCESSING CENITIR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 9072;1 <br />