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<br />INS`1,`RIJC'170N,S IrOR COMPIX'FINCi FORM SB -
<br />GENERAL INS"IR UC11ONS.
<br />1. One FOWNI "B" shall be completed lot, each tank for all NEW DRi Iii, RERMrf- CHANGES, REMOVAUS and/or any
<br />other TANK, INFO RMA310N CHANGI,
<br />2. This forin should be completed by 6ther the PERMrr APPLICANT, or the LOCAL AGINCY UNIMIRGROUND TANK
<br />INSPECI'OR�
<br />3, Please type or print clearly all requested information.
<br />A. Use a hard0 ,
<br />point writing instrument, vou are;m 3 codes.`
<br />TOP OF FORM- *MARK ONLY ONE ITEM*
<br />L Mark an,,,"') in the box next to the iicm, hat best describe,,; r the form, is being completed.
<br />2. Indicate 0-,e DBA or Fa hr nanic, tank is inswllc,`
<br />IF UNKNOWN S"MiCIlry
<br />A, Indicate oxners tank ID If thcre iia lunik number that is loy the owTer to identify the tank (ex. AB70789).
<br />B, Indicate lln<,, name of the compwiy tha,. n,,mufacturcd the ACMI.�VIANK MFG,).
<br />C. Indicate fa <i year the tank was installol, 1,987).
<br />D. Indicate the tank capacity in gallons (ey , ',(0) or 10,000 etc.),
<br />It TANK CON'J'EMIN
<br />A. L If MOTOR VEHICLE, FUF"L, check box'l and complete items B & C,
<br />1 If not \401 OR V11 ITCLE FUEL, cheek the appropriate box in section A and complete items B 1).
<br />13, (,'heck the appropriate box.
<br />C, Check The e typ of MOTOR VEITICL[ FUEL (if brix I is checked in A),
<br />D, Print the chemical name of die hazardous substance stored in the tank and the (',A,S,#. ((Chemical Ab. strict Service
<br />number), i1' box I is NOT checked in A,
<br />III TANK CONt�17JURNION to R. 01413 T1"I3M ONLY IN 13OX A, 13, C, & D
<br />1, Check on'y one item in TYPE OF SYSTEM, TANK MATERIAL, EN11713RIOR. LINING and CORROSION PROTEIC7110N,
<br />2, If CTIA L, print in the space provided.
<br />IV. PIPfN(; INPORMKIION
<br />L Cirele A if above ground; circle U if underground; and circle both if applicable.
<br />1 If UNKNOWN, circle; or if 0111ER, print in space prcVidcd
<br />3. Indicate the 1,11AK DETECTION system(-,) used to comp)ywith the monitoring requirement for the pipits;;,
<br />V. TANK LFA K D1yI1!C`1'1ON
<br />1. Indicate the LEAK DE -1 I ECII(',)N system(s) used to cornply with the nionitoringrequirements for the tank.
<br />VL INIURMNIION ON TANK PERMANEW11M CSI ST IN PIACM
<br />1. SIIMATED DNIT", LAS"1'USFD - MON"1"1JJY1-,,1,AR (January, 1988 or 01/88�k
<br />1 [.,M'IMATFD QUANFITI'Y of HAZARDOUS SUBS�IANCI,71 remaining in the tank (in Gallons).
<br />3. wAs'rANK FILLED WITH INERTMA11"RIAL? Chcek'Yes'or 'NO'.
<br />APPI.ICAMI'MUSS 7SIONAND DNrE11111 FORM AS Thal I(:K119.),
<br />INFFRUC711ON ItOR'111E LOCAL AGENCRIS
<br />I'lle state underground storage twik 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 sarne as shown in fount "A", 1"he
<br />tank number Iney be assigned by the local -
<br />agency
<br />, however, this nurniier must be numerical and cannot contain in alphabet. If
<br />The local agency prefers the State Board to assign in(, tank number, please leave it blank,
<br />a IS711E RESPONS113111rY OF111E LOCAL AGFNCY 'III/Vr FA(,'IlXry '110 VBR
<br />CIFT
<br />ACURACY OF ITIE 1NF()RM)VI1ON. 111E I,OCAL AGENCY IS RENK)NSIBLE FOR'llm commgr[Olsl Olt"1111f
<br />'LO GAL AGIINCY USH ONLY' IN1O2MN110N BOX AND IK )R FORWARDING ONE IK) ti IX ANT) AS&)C1XI1iD
<br />FORM 'B'(s) TO 111H ItO11,0WING ADDRIAN&
<br />9I*A'J1,' OFCAMFORNIA
<br />WNll'at' , RI COMI'R-01, BOARD
<br />1)XyIA PROCF.SSINO CI'1'1,iN14,,,k"1
<br />P.O. BOX 527
<br />PARAMOUNI-, CA 90M
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