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INt'RIX 1'ICIi RI11. COMPINYING I d "M
<br />1. One FORM 'B" shall be completed for each tank fres all NEW PEiI2 IS, PERmrr 1ANG -S,, REMOVALS and/or any
<br />otherTANK IWORMA11ON CHANGE
<br />?
<br />2, is form should be completed by either the PI!Rmrr APPI.ICANr or the LOCAL AGINCY UNDEIR i C)I ND TAN
<br />I SPEC170II..
<br />3. Please type or print clearly all requested information.
<br />, Use a hard rxnnt writing instrument, you are making 3 copies.
<br />TOP OF ONLY Y )NE til W
<br />1. Mark an (X) in the box next to the item that best describes the reason the farm is being Completed,
<br />2. Indicate the DBA or Facility name where the tank is installed.
<br />I. TAN D SCRIPnO - COMPLIffE All, T1 S -IF UNKNOWN SPIXIFY
<br />A. Indicate owners tank 11) # : If there is a tank number that is used by the owner to idem
<br />Il. Indicate the name of the company that manufactured the tank (ex. ACME TANK MFG
<br />C. Indicate the year thy, ,r,tak was installed (ex. 19€37).
<br />D, Indicate the tank capacity in gallons (ex. 15,000 or 10,0.00 etc.).
<br />IL TANK CON11:11NIS'
<br />A. 1., If MC)'FOR V14-111CLE I J mI„ check box I and complete items B & C.
<br />1 If not 'ti107FOI2 VI4,111C L FUEL, check the appropriate bait in section A and comple
<br />I3, Check the appropriate beau.
<br />C. Check the type of iCi(I"pOR VEHICLE F".1, (if box i is checked in A).
<br />D, Print the chemical name of the hazardous substance stored in the tank and the C,A.S.#.
<br />number), if box I is itiGF elhecked in A.
<br />11I. TA (X)N91'RU 0 - MARK 01 I3.n E ONLY IN BOX A, 11, Cf & 1)
<br />1> Check only sant; item in T PE OF S 4I'I3t%1, TANK MA°t ERIAL INTERIOR LINING
<br />2, If O`1'IIER, print in the space provided.
<br />IV. PIPING INFORMATION
<br />1. Circle A if above ground, circle lI 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 -712(7'100 system(s) used to comply with the monitoring'requirci
<br />V. TANK LFAK DrTnX7110N
<br />1. indicate the LEAK system(s) Used to comply with the monitoring;requirei
<br />1, N ItMtC'lEDIA`Ii; T.AS`I' USED - MI ON-I'II/YEAR (.January, 1988 or 01/88).
<br />2, ESTIMATED (,FCJt1NIT]"F of TIA7ARDOUS SUITS"I"A CE remaining; in the tank (in s
<br />3, WASTANK FILLED Wrl11 INN.,, i° rERIAL? Check 'Yes' or `HCl'.
<br />A PLP " Thi' 17SIGN AND DX11,1IIE FORM AS I IIICAID.
<br />1N,5rRUC;17O 1Z ° III?' I. ACi C:M0S
<br />The state underground storage lank identification number is comprised of the two digit couq
<br />number, the six digit facility number and the six dight tank number. The county and )urisdicti
<br />can be obtained lay callzng the State 11oard (916)739-2421. °Ilan: facility number must be the s
<br />tank number may be assigned by the local agenc),; however, this number must be numerical a
<br />the local agency prefers the State hoard to assign the tank number, :please: leave it blank,
<br />I'I' IS THE RESPONSIBfIXIT t }F 1111; LOCAL AGENcy 'I wr F S'I"I°C A "I IIIi izma
<br />NI i OF CA11FORNIA
<br />NT IC.0X)URCT_1 _ I ' ` i BOARD
<br />/o sm.irl I? P. ,
<br />DATA PROC I S,SINCa" CENIER.
<br />P.O. 13OX,527
<br />PA C7t , CA W/23
<br />y the tank (sax. A1170789).
<br />items B D.
<br />"heroical Abstract Scmice
<br />t for the piping.
<br />for the tank,
<br />
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