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IN,%-I'RUCIIONS MR COMPLVIING FORM *B* <br />GENERAL INSTRUC11ONS- <br />1. One FORM "T3" shall be completed for each tank for all NEW PERMITS, PERMIT Cl IANGI.,;S, REMOVAI-S and/or an" <br />other TANK INFORMATION CIIANGE. <br />2. This form should be completed by either the PERMrr APPLICAM'cir the IX)CAI. AGENCY UNDERGROt)NDTANK <br />INSPBC170R., <br />3. Please type or print clearly all requested information. <br />4. Use a bard point writing instrument, you are making 3 copies. <br />TOP OF FORM: *MARK ONLY ONE 1`11M <br />1. Mark an (X) inthe box next to the item dial 'Nest describes the reason the form is b cing completed, <br />2. Indicate the DBA or Facility name where the tank is installed. <br />I. TANK DF-SCRIVIION - COMPTIME ALL ITEMS - IF UNKNOWN -SO SPECIFY <br />A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank ux. Ail70789). <br />0789). <br />B. Indicate the name of the company that rnirrmfactured the tank (c)✓"l:; TANK MFG.). <br />C. Indicate the year the tank was installed ((,x. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,W or 10,(00 etc.). <br />H. TANK CON'I1zNTS <br />A, L If MOTOR VE.111CLE FUITL, check box I and complete items B & C. <br />2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items I? & 1). <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE FUEL (if box I 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 />III. TANK CONSTRUCTION - MARK ONE rIFM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTEC110N. <br />2. If OTHER, print in the space provided, <br />IV. PIPING INFORMATION <br />1. Circle A if above ground; circle 11 if underground: and circle both if applicable. <br />2. If UNKNOWN, circle; or if OTHER, print in space provided, <br />3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DU1711)(711ON <br />L Indicate the LEAK DEFECTION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMA'nON ON TANK PERMANEN17,Y CLOSED IN PtACM <br />1. ES'11MATED DATE, LNST USE 1) - MOINZ1.1liYEAR (January, 1988 or 01/88). <br />2. IFS114IATED QUANTITY of II)'\ZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or WO', <br />APP11CANT MUST SIGN AND DWI7E '111E FORM AS INDWATE0. <br />INSTRUCTION FOR'nIE 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 areP redetermined 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 />IT IS THIS RasmNsmuxl-y Ovum LADcAL AGENCY '.nIA`I'1NSPIX.3N'17IIE FACIIn`YTO VIFRH?Y'IIIE <br />ACCURACY OF TIIE INFORMAITON. ITIE DOCAL AGENCY IS RESPONSIBIA.- FOR'ITIE COMPLH11ON OF TIIE <br />'I,OCAL AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM 'A' AND ASSOCIATED <br />FORM -Ir(s) T-017111 FOLI OWING ADDRESS. <br />SFATI! OF CALIFORNIA <br />917NILT WATER RE -SOURCES 0ON`1`ROL BOARD <br />C/o S.W.E.E.P.S. <br />DATA PROCT.SSINCY CEN717ER <br />P.O. BOX 527 <br />PARAMOUNT, CA %M <br />