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IAd`T.`txllt;ITO S FUR CC)IoS'HU I CT IX)III 'Ir
<br /> GENERAL INSWIZU(711ONS:
<br /> 1; One FORM "B"shaft be completed for each tank for all NEV PERMU-S,P ERmn,(IIA CY&S, REMOVAIS and/or any
<br /> otherTANK 1NIX)RMAA10N CHANG11
<br /> 2. This form should be completed by either the I'I:i U AT'PUC'.AN17 or the I. L AGEI.fNI)13 izltt)7JND I'ANir
<br /> JNSPI: 71'ORa
<br /> 3. .Please type or print clearly allrequested information.
<br /> T.Jse a hand point writing instrument,you are making 3 copies.
<br /> TOP OF FORM-'AMRK ONLY ONU num,
<br /> I. Mark an(; )in the bOK next to the itCra that beast describes the:reason the Purist is being completed.
<br /> ). Indicate the l)13A or Facility name where the tank is installed.
<br /> . TANK 1)I1-CXMI1 1100-C",OMPL FF,ALL r11I S-IF UNKNOWN-SO SPFXNTN
<br /> A. Indicate owners tank ID#-If thea is a tank number that is used by the owner to identify the tank (ex.,A1370789).
<br /> 13. 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 /> D. Indicate the tank:capacity in gallons (ex.2.5,(,XX)or 1.0,W0 etc.):
<br /> IL TANK CON11 I
<br /> A. I� If MOTOR V14111(1,U FU1 l,check box 1 and complete items B&(I
<br /> 2.If not MOTOR VEHICLE FUI;I.,,check the appropriate box to section A and complete items B 1),
<br /> I:3. Check the appropriate box
<br /> C:. Check the type of mCYi'C")R VEHIC'LL FUEL,(if box 1.is checked.in A).
<br /> D. print the chemical name of the hazardous substance stared in the tank and the C.A.S. .(Chemical abstract Service
<br /> clamber), if box 1.is NOT checked in A.
<br /> III. `'AINK CC) , UC717O ..MARK ONE rll3M ONLY IN BOX A,B,C:&I)
<br /> I. claeak only one item in'l"YPE OF SY9l'FM,Tr %NK ts1,'t1TRIAL, IN71 RIOR LINING and CORROSION PI$C3T (TTION".
<br /> 1 If i3T Ilan,print in th(,sp<acc prop iatcci.
<br /> IV, PIPING I"i" I1)IC A'I"IC)N
<br /> 1, Circle A if abo,,T ground:.circle U if underground; and circle troth if appiic;able.
<br /> 2. If UNKNC WIN,circle or if OTHER,print in space, provided.
<br /> 3. Indicate the LEAK D17FIX:[IO aystent(s)used to comply with the monitoring recluireme it for tits piping.
<br /> V. `IANLEAK 3III"I?C'".I'IOI
<br /> 1. Indicate the LEAK I)I,I'l (7I1ON system(s)used to comply with the monitoring requirements for the tank.
<br /> V1. INFORMA11ON ONTANK I"I3R ANINI1,Y CLOSED IN PIACI?
<br /> f I,SI I ATM) Irt1'I'C I.AS"I"I Slid) -aMO III/YEAR(January, 1ST 8 or 01/88).
<br /> 2, ESFIMAT1.1.1) QUANITI"Y of IIA7ARDOUS SUBS-"ANC1."remaining in the tank(in Gallons).
<br /> 3. WAS TANK I'LLED WITH INERT NIA'CEMAi:a Cheek'"Yes'or'N(Y.
<br /> AIgpfl cwr mula SIGN AND I)ATP 1717 Ik)RM AS I DIGNII I).
<br /> imf t R FC FI(7 ItOR717111 LOC°.ani,AGI:It 01
<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 sixdigittank number. 'I'he county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the State T3oarel(916)739-2421. 'I`he 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 /> rr IS°DTII RES 31111'Y OF°111 E LO A(ix1,�7S I(7X I IN.I'I SPI:X,I °171I3 FA('1Lr IDs12 °fi l a
<br /> ACCURACY 017°171Iz I F 'IIO . °I71I?I AL A(al NCY IS T2ESI ONSIBLE FOR 11111 COMIFUNION 01711113
<br /> "LOCAL AGTiN(Y USE ONLY'' I ) NTIC) MIX AND FUR FORWARDING(IEEE?1a()1tM W AND A:`s.SO "IUD
<br /> FORM W(s)T011111 I LLO INN AI)DRE&S.
<br /> rNll?OF CAUFOR iIA
<br /> i°tYI73A° Ii RIL%01JR I (C►brT"lt()Im It() l)
<br /> c./c)& .IhI;h.&
<br /> I rA P 3()C I SI Ci(MN`1 "sit
<br /> P.O.BOX 527
<br /> PAI 1C UNF,C". a
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