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M; Y7, W,, ITIFI­ <br />INS-IRUMONS FOR COMPLVIING FORM *W <br />GENERAL INS17RUC711ON& <br />1. One FORM "B"shall be completed for each tank for all NEW PERMIT'S, PFIRMH'CHANGES, REMOVALSand/ Or 1MV <br />other TANK INFORMAITON CIIANGE. <br />2. This form should be completed by either the PERMIT APPLICA.M.1. or the LOCAL AGENCY UNDERGROUND TANK <br />INSPECMR. <br />1 Please type or print clearly all requested information. <br />4. Use a hard point writing instrument. you are making 3 copies. <br />71OP 017 FORM: 'MARK ONLY ONE ITEW <br />1. Mark an (X) in the box next to the item iia.' -lest describes the reason the form is being completed, <br />2. Indicate the DBA or Facility name where the tank is installed. <br />1. TANK DFISCRIMON - COMPIE1117 All. rIT-24S - 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 A1370789). <br />B. Indicate the name of the company that manjactured the tank (e«_ 1,,CVE TANK MFG.). <br />C. Indicate the year the tank was installed ((,x. 1987). <br />D. Indicate the tank capacity in gallons (ex. 2.5.000 or 10,000 etc.). <br />H. TANK (X)".MS <br />A. 1, If MOTOR VEHICLE FUE"L, check box I and complete iterns 13 & C. <br />2. If not MO'T'OR 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 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 CONSTRUC'T'ION - MARK ONE r1FM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OFSYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTEC.1,10N. <br />2. If OTHER, 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 />1 If UNKNOWN, circle; or if OTHER, print in space provided. <br />3. Indicate the LEAK DETEMION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DUIIIC1710N <br />1. Indicate the LEAK DE-I'EMI.ON system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PERMANIMMY CLOSE0 IN PIACH <br />1. 01MMAlMD DATE LAST' USED - MON`I'II/yEAR (January, 1988 or 01/88). <br />2. FS11MATED QUAN`ITI'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WFIJI INERT MMURIAL? Check 'Yes'or 'NO'. <br />APPLICAN717 MUST SIGN AND DAFE'I11E FORM AS INDIC1tiI10, <br />INSTRUCTION FOR'nIE LO(_:AL 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 assiged 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 />rF IS THE RF—SPONS113HXI'Y OFTTIE LOCAL AGENCY 711INFINSPECTS 11113 FAcun­y To VERIFY 71111 <br />ACCURACY Of' THE INFORMA11ON. IIIE LOCAL AGENCY IS RESPONSIBI.J.- FOR '111E COMPLETION OF 111E <br />*LOCAL AGENCY USP ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM *A* AND ASSOCINIM <br />FORM "33"(s)170.11111 FOI."WING ADDRESS. <br />SPAM OF CA11FORNIA, <br />SPATE WA71TR RESOURCES COMI'ROL 130ARD <br />C/o Sm-RILP.s. <br />DATA PROC'ESSING CWMR <br />P.O. BOX 577 <br />PARAMOUNT, CA 90M <br />