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<br />ENS°I"F�Uf.I710NS A'SfS^L COMI�EITHNC1 MRM -gB r
<br />GENERAL INS IIU(TGONS:
<br />1. One FOPUM "B" shall be completed for each tank for all NEW E: S, PlillMrr CHANCBE1S, + 'CJVAI and/or any
<br />other TANK INItORMA17ON CHANGE
<br />2, This form should be completed by either the PERMI71'APPLICAMr or the LOCAL AGENCY UNDERGROUNDTANK
<br />INSPECrOR.
<br />3. Please: type or print clearly, all requested information,
<br />4, Use a bard pointwridng instrurait,w, you are making? 3 copies.
<br />Iop LD1= IN)RM. "MARK ONLY ONE TIEN*
<br />1. Mark an in the box next to the item that Fest describes the reason the form is being completed.,,-,
<br />2.
<br />ompleted..-
<br />2. Indicate, the b8Aj y I%ciIhy.name. where the tank is installed.
<br />I. TANK DFSCIt 11ON _ , MPL :nM All, nl:? S - W UNKNOWN ro SO SISWIFY
<br />A. Indicate owners tank ITS # - If there is a tank number that is used by the owner to identify the tank (ex. AB70789).
<br />& Indicate the name of the company thatmanufactured the tank (ex. ACMETANK MFG.).
<br />C. Indicate the year the tank was installed (ex, 1987).
<br />D. Indicate the tank capacity in gallons (ex. 2.5,000 or 10, etc.)
<br />11. TANK C_O z rS
<br />A, L If MOTOR Vi:HICLE, FUEL, check box 1 and complete items IB & C.
<br />2: If not >°��3"�ORi F°IICL,L. FUEL, check the appropriate box in section A and complete; interns B & 11
<br />fl. "' 6ieik the alrprofYriate box.
<br />C. Check the type of MOTOR VEHICLE; Is"F7EL, (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 />number), if box 1 is N€ T checked in A.
<br />III. TANK CONS71MI:i07ON - MARK ONE ONLY IN hOX A, 1B, C: & 1)
<br />1. Check only one item in'FYPE OF SYSTF,IM, TAMC MATERIAL, INFERIOR LINING and CORROSION pI2OTEC110N.'
<br />1 If OTHER, print in the space provided.
<br />IV, PIPING IMI) "IION
<br />1, Circle A if above ground; circle IJ if underground; and circle; both if applicable,
<br />2. If UNKNOWN, circle; or if OTHER. print in space provided.
<br />3. Indicate the LEa1IC DETEC=TION system(s) used to comply with the monitoring; requirement for the piping;,
<br />V. TANK LEAK DM FI.CI'I0N
<br />3. Indicate the LFAK DE. I'E ION system(s) used to comply with the monitoring requirements for the tank.
<br />Ia_ FMORMATION ONTANK 'PER ANHVIMY CI.CI,SS'ED Its PLACE
<br />E
<br />1. E,STIMAIT.0 DATE I. ASF LJS D - MO I`FI/Y „ IL (January, 1988 or 01/80.
<br />2. ESFIMATED QUANIJTY of I AZ"ARI)OUS U BSI°ANCE remaining in the`tank (in Gallons).
<br />3. WAS TANK Fllli'D WITII INE I<I' c "I"ERIAI.,°t Check 'Yes' or 'NO%
<br />APHICAN17 MUSTSIGN AND DAM1 °I11E? ItORM AS INDICATED,
<br />UCI10N FOR711F. LOCAL AGF CII-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 nurnber, 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". 'phe
<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 />TI' IS °I°IIE? ItI?.S'I omsiIBI[,EI'Y° of °I1I t ICI A(aI?NC Y °I1TAI" I ISpIx IMS "IIID FAC`.II.aI ry M. VERIFY1111.11
<br />ACCURACY 01r 'I'III? 1M70RMNI70N. 'IIID LOCIU, AGENCY IS RESPONSIBLE FOR 'I'I:IE COMPLINION 01111111
<br />'LOCAL AGENCY USE ONLY' R A`I ICIN BOX AND FOR 17ORWARDING ONE FORM *A" ANIS ASSOCIATED
<br />FORM 'B'(s) 710 THE fk)LI WING AI3T)RIISS.
<br />91'AlE OF IJiFO NIA
<br />SENIT" WA°lU iryI.�1OURC'17S, CONUIRO L BOARD
<br />DNFA eic & INCi CENFER
<br />P,OC BOX 527
<br />ISA MOUNI', CA
<br />
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