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GENERAL rN,`;I'R1JCi IONS:
<br />I. One F€)RM 'B" shall be completed for each tank for all NEW PE Vii, ISI Rmn, I NG -S,I C VAI and/or any
<br />otherTANK IN1k)RMX170N CHANGE
<br />2. This form should be completed by either the PERMIT APP11CANTor the IX)CAL AGENCY UNDERGROUND TANK
<br />I , EC"I"C)12_
<br />3. Please type or print clearly all requested information.
<br />4. Use a hard point writing instrument, you are snaking 3 copies,
<br />TOP OF 11ORIVE 'MARK ONLY ONE r1EM'
<br />1, mark an (X) in the box next to the item that best describes the reason the form is being; co ttpleted.
<br />2. Indicate the. I)I,A or Facility name where the tank is installed.
<br />L TANK D I,SC I'IC) - COMPLfM I L 171 S - W UNKNOWN - SO S'PI
<br />A. Indicate owners tank 11) # - If there is a tank number that is used by the owner to identify the tatty fcx� A[37078,9):
<br />B. Indicate the name of €lee company that manufactured the tank (ex. ACMETANK ANK MFG.).
<br />(1 Indicatehe i ar tt'a, ,chalk was installed (est. 19137).
<br />1). Indicate the tank capacity in gallons ;(ea. 2.5,000 or 10, etc.).
<br />11. TANK CONIENI'S
<br />A, 1. If lvti3"I'O VF -'111C LE FUEL, check box I and complete items ft & C.
<br />2, If not :SIC?"t`C)II VI;IIIC LE FUEL, check the appropriate box in section a and complete items B I).
<br />11. Check the appropriate box,
<br />C:. Check the type of MOTOR VEHICLE FUEL (if box 1 is checked in a).
<br />C), 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 N(YI` checked in A.
<br />II1, °I°AN ()ON I`IRLI ON - MARK ONE rIMM ONLY IN W)X A, ti, C & I)
<br />1. Check only one item inTYPE, O S`4"iEEM, l:ziNK MATERIAL, ., IN'IERI€ R LINING and CORROSION 1'ROTE (TION.
<br />2, If O'11Iia,Ci, print in the space providcd.
<br />IV. PIPING fk)R A`1'IC)
<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 LAK D1 l;i' ION system(s) used io comply with the monitoring requirement for the piping.
<br />V. TANK LFAK DHIM(7nON
<br />1, Indicate the LEAK I) CHOLA systems) used to comply with the monitoring requirements for the tank.
<br />I. INFORMNITON ONTANK PERMANEN11MCIAXSED IN PLACE
<br />1. E:i"I ii4A`EED DATE, I AST USED µ C) I'II/ a it (January, 1935 or 01/811).;
<br />2 E 5171 A'I"E D QUANTITY Y of HAVARDOUS SUBSLANC E remaining in the tank (in Gallons).
<br />3. WAS 'I'ANK HLLE"D WrIll INI R17 al 11AL? Cheek 'Yes' or WO',
<br />PPI .I;f SIGN AND E'SW111 `i"llt: 14ORM AS I [I)ICAI).
<br />'Phe 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, ne county and jurisdiction numbers are predetermined and
<br />can be obtained by calling the State hoard (916)739-2421. The facility number crust be the sante as shown in form "a". 'E7ae
<br />tank number may be assigned by the local agency-, however, this number must be numerical and cannot contain an alphabet. If .
<br />the heal agency preferstheState; Board to assign the tank number, please leave it blank.
<br />f IVITIE R&SPONSIB1111T OF'11111,I s AGENCY Y I'i1z r I Sprx, °t"lm manny To virRIFY 11111
<br />AC , C'Y 01VIIIE III ORMA110 . 'HIE LOCAL L AGHT ICP" S RENTONSHRE FO 'IIID C'C 'L,I,`11ON C)Ir 71, 11 ,
<br />*IX :, L AG124CY USE € NLY" i '11()N BOX AND MR 1K)RWARDING ONE OV AND S' °I°1?I.)
<br />FORM 'W(s) TO'111E FOLLOWING AIYDRE,&&
<br />s I A"I , OF CALIFORNIA
<br />:I ""ASI` ? WNIER 1IA':A)1.1I1C", ,S CON i ROL I X )ARD
<br />P.0, IXYX 527
<br />PARAMOUNT. CA &
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