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<br /> INI;I'R(.J('IION,S Ik)R COMPTJnTNIC; FORM"I3"
<br /> GENERAL INSTRUCAONS:
<br /> 1. One FORM "B"shall be completed for each lank for all NEW PT-.W. VI.N,PERMIT CIIANGES, RE.MOVATIS and/(3rand
<br /> other TANK INFORMATION CHANG11
<br /> 2. This form should be completed by either die PERMIT APPI.ICAW 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 rre making 3 copies.
<br /> TOP OF FORM: *-AMRK ONLY ONE rLim,
<br /> 1. Mark an (X)in the box next to the item lA,,V)cst describes the reason the form is tieing completed.
<br /> 2. Indicate the DBA or Facility name wbereflne tank is installed.
<br /> I. TANK DEW—RIPnON-COMPLIMM,All,M-rMS 1 Alr t-NKNOWN-So Sillt.AFY
<br /> A. Indicate owners tank 11.) #-If there is o r,:n% i-'umber that is w,,�,d �>v 1,:)c owner to identify the tank (ex.A1370781)).
<br /> B. Indicate the name of the company that n lured the tank ',!]-!TANK MFG).'
<br /> Cl. Indicate the year the tank was installed
<br /> D. Indicate the tank capacity in gallons 2Z, 'r 10,000 cfc,)
<br /> IL TANK CONII.WLS
<br /> A. L If MOTOR VEHICLE FUEL,check b<,-)x i end complete items B & C.
<br /> 1 If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B R 1).
<br /> B. Check the appropriate
<br /> (I Check the type ot'MOTOR VEHICLE,FUEJ,(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 Set-vice
<br /> number),if box I is NOT checked in A.
<br /> III. TANK CON91RUC`11ON-MARK ONE n'EM ONLY IN BOX A,B,C&1)
<br /> I. Check only one item in TYPE OFSYSI'EM,TANK NIAITIRIAL, INTERIOR LINING and CORROSION PROTE"CTION.
<br /> 2. If 0'171113R,print in the space provided.
<br /> IV. PIPING INFORMAT[ON
<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 l, K DETEC.11ON system(s)used to comply with the monitoring requirement for the piping.
<br /> V. TANK LEAK DULIX711ON
<br /> 1. Indicate the LFAK DETECTION system(s) used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMATION ON TANK PERMANENII.Y CLOSE(IN PLACE
<br /> 1. Es-rimATED DN17F.LAST USED-MON'111/YFAR(January, 1988 or 01/88).
<br /> 2. ESTIMATED QUANTITY of IIAZARI)OUS SUBS-LANCE remaining in the tank(in Gallons).
<br /> 3. WAS TANK FILLED W17111 INI.I.IZI'MATE-I'RIAL?Check'Yes'or'NO'.
<br /> APPLICANT NWS`Y`SIGN AND DATE111H.FORM AS INDICATED,
<br /> imsmucnm POR TME 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 /> rTIS TILE RESPONSIBILITY OFTIIE LOCAL AGENCY ITIA17 INSPEC'[Nntu FACILITY TO vERIL-Y TtiE
<br /> ACCURACY OFTLIF,INFORMATION. nIE I.00AI,AGENCY IS RESPONSIBLE FORIIIE COMPIH11ON OFIME'l
<br /> ,N
<br /> '1,OCA1,AGENCY USE ONLY*INFORMN11ON BOX AND MR FORWARDING ONE FORM W AND ASSOCINITI)
<br /> FORM-1r(s)T(.)'I11E FOIIOWIW3 ADDRESS.
<br /> STA`ni OF CA11FORNIA
<br /> SLATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.F.S.
<br /> DATA PROCESSING CEMI17,R
<br /> P.O.BOX 527 ..
<br /> PARAMOUNT',CA 90323
<br />
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