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INSIRUCTIONS FOR COMPLETIING FORM QB" <br /> GENERAL IN .. IJ . ONS <br /> L One FORM "I1"shall be completed for each;tank for all NEW PERMIT'S,PER rr CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANG4, ... : . .,,, . `. <br /> ?. This form should be completed by either the PERMrr APPL.IC" or the 1.06i A'GENCY UNDERGROUNDTANK <br /> INSPECTIOR- <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3,copies,. <br /> 17OP OF FORM:"MARK ONLY ONE Iii" <br /> 1. Mark an (X) in the box next to the item that best describes the reason the fort„ is being completed. <br /> 2. Indicate'ti DBA or Facility name where the tank is installed. <br /> I. .rANK DES CP`1-(0N I..I?1I ALL ITHMS-IF U -SO SPIX d "y <br /> A. Indicate owners tank ID #r If there is a tank number that is used by the owner to identify-the-tank(ex.AB70789)e <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMETANK MF(3.). <br /> C. Indicate the year the tank was installed(ex. 1987): <br /> D. Indicate the tank capacity in.gallons(ex.25, or 10,000 etc.). <br /> 11. TANK 1 I':i <br /> A. 1. If MOTOR VET IIC`"I I:?FUEL,check box 1 and complete items B &C. <br /> 2.If not MOTOR VEHICLE FC7E.L,check the appropriate box.in section A and complete items it&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 1.is NOT checked in A. <br /> II.I. TANK CONS . UCTION K O ONLY IN BOXA,II,C,°&D <br /> L Check only one item in TYPE OIC SYSTE M,TANK MAUMIAL,INTERIOR LINING and CORROSION 1'.RoTEC`TION. <br /> 2. If OTHE IR,print in the space provided: <br /> . PIPING INFORMATION <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 DETE-CTION system(s) used to comply with the monitoring requirement .for the piping. <br /> V. TANK LEAK DI? ON <br /> 1. Indicate the LEA,AK DT;'"I"ECTION system(s)used to comply with the monitoring requirements for the tank. <br /> AMON ONTANK PirRmANFmirLy CLOSED PLACE <br /> 1. ESTIMNITD DATE LA:4."I'USED-MON'TI-I/'YE;AR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUAN`ITFY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), <br /> 3. WAS TANK FILLED WTTII INERT TE-RIAL?Check'Yes'or'NO'. <br /> APPLICANr musr SIGN AND DAwnm FoRm As micATED. <br /> INSTRUCTION ICOR.TIIE LOCAL AGEN S <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 /> IT IS THE RESPONSIBILITY OF IE3 I AC,I?,N 'IIIA°I'INSPFX-1,S 771E FA.o r1'Y TO VERIFY111E <br /> ACCURACY OF 17 'TION. 111E LOCAL AGENCY IS REi,SPONSIBIJi FOR TIM COMPL ITON OF THE <br /> 'LOCAL AGENCY USE O B ITON 13OX AND FOR FORWARDING ONE FO `A'AND ASSOCIA~ITI) <br /> FORM-W(s)TO 31111 FOLLOWING ADDRI.!SS. <br /> SIE CALIFORNIA <br /> 91WIM WATER R13SOURCEN C ONFROL BOARD <br /> C/o S. jur.P S. <br /> DATA PROCM&SING CINTIM <br /> ?R <br /> P.0) K 527 <br /> PARAMOUNT!,CA 90723 <br />