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INSTRUCTIONS FOR COMPLETING FORM PDP, <br />GENERAL INSTRUCTIONS: <br />1. One FORM 'B" shah be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any <br />other TANK INFORMATION CHANGE. <br />2. This torr should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br />INSPECTOR. <br />i �3, Please type or print clearly all requested information. .. <br />4° Use a hard point writing Instrument, you are making 3 copies. <br />TOP OF FORM: `MARK ONLY ONE ITEM" <br />1. Mark an (X) intho box next to the 'item that best describes the reason the farm is being completed. <br />2, Indicate the D15A or Facility name where the tank is installed. <br />Ir TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br />A. Indicate owners tank ID # .. If thei ais a tank number that is used by the owner to identify the—,tank <br />(ex. AR70789). <br />B, 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. 25.000 or 10,000 etc,) <br />II. TANK CONTENTS <br />A. 1. IF <br />MOTOR VEHICLE FUEL, check box I and <br />complete items B & C. <br />2. If <br />not. <br />MC;?OR VEHICLE FUEL, check the appropriate <br />box in section A and complete items B R D. <br />E. Check <br />the <br />au propriate box.} <br />C. Check <br />the <br />type of MOTOR VEHICLE. FULL (if <br />box�I is checked in A). <br />D. Print. <br />the <br />chemical name of the hazardous <br />substance stores; in the tank and .the C.A.S.#. (Chemical <br />Abstract <br />Service number), if box .1 is NOT <br />chocked in A. <br />III. TANK CONSTRUCTION K ONE ITEM ONLY IN BOX Aa B. C <br />1. Check only one item 'in TYPE OF SYSTEM, TANK MAIERI.AL, INTERIOR LINrNG and CORROSION PROTECTION.2, If 01H R, print; in the space provides,, ' <br />IV. PIPING INFORMATION <br />I.;'i rc l e A i f above (ground ci rcl e U i f 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 />1.. Indicate the LEAK DETFCTION system(s) used to COMPly with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1 ESTIMAi ED DATE L.ASI USED - M,) iHr Y _AR (,January. 1988 or 01/58) <br />2. ESTIMA:ED OUTANTITY of HA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. 11AS TANK 1=ILL.ED w1TH INERT MATERIAL.?Check 'Yes' or, 'NO' <br />APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED, <br />INSTRUCTION FOR THE LOCAL AGENCIES <br />The stateunde,i;round storage tank identification number is composed of the two digit county number, the three <br />digit urisdici-icfn number, the six digit facilitry number and the six digit tank number, fhe-county and <br />jurisdiction numbers are predetermined and can be obtained by calling the State Board (916) 2211-4303. the <br />facility number must be the same as shown in form "A" The tank number may be, assigned by the local agency, <br />however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State <br />Board to assign the frank number, please leave it blank: <br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br />INFORMATION, THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX <br />AND FOR FORWAROING`'ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. <br />