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i�- . 777W -,7' - -77 <br /> IN91RUCIIONS POR COMPLUPING,FORM"Li" <br /> CyENI1'.RA1.IN,';1`RUC-nONS- <br /> 1, One FORNI"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGES, REMOVAUS and/or any <br /> other TANK IM70RMAIION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC170R. <br /> 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 IrI71,2W <br /> I. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DES CFvI1ON-CX)MPILrIE All.IrIIWS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.AB70789). <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 /> H. TANK CX)INTENrS <br /> A. 1. If MOTOR VEHICIII.."FUEL,check box I and complete items B &C. <br /> 2. If not MOTOR VE�HICLE FUEL,check the appropriate box in section A and complete items B & D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHIC114'.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 I is NOT checked in A. <br /> III. TANK CX)N',I;rRUCI'ION-MARK ONE M'IM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INI'ERIOR LINING and CORROSION PROITI�CTION. <br /> 2. If OTIIEP,print in the space provided. <br /> IV. 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 DE FE'criON system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DOMI(NION <br /> 1, Indicate the LEAK DUIT"CTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMKIION ON TANK PERMANEN11.Y CIAMED IN PLACE <br /> 1. ESTIMATED DAI 1, LAST USED-MONTII/YEAR(January, 1.988 or 01/88). <br /> 2. F—";I'IMATEI) QUANFrl-Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT'MA171"RIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DNIl.'`111H MRM AS INDICKFED. <br /> INSTRUCTION FORT1113,LOCAL AGENCIES <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 Sta*c Board to assign the tank number,please leave it blank. <br /> II'IS111E RFSPONSIBHXI'Y OF TIIE LOCAL AGENCY 11INFINSPIX71S ITIE FACH117Y TO VERIFY <br /> ACC URACY OF 111E INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 111E COMP1171ION OF TIIE <br /> *LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM'A*AND ASSOCIATED <br /> MRM-B-(s)TO-11111.FOLLOWING ADDRESS. <br /> STN11i OF CALIFORNIA <br /> 9FA7111 WNIV R RESOURCES CONTROL BOARD <br /> C/O&W.Li E.P.S. <br /> DATA PROCESSING CMNITIR <br /> P.O.BOX 527 <br /> PARAMOUNT',C.A.90M <br />