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IN i.CItUC;i CIN roFOR MMPIX�ITNG FOIRM'B'
<br /> GENERAL INS-MUCIIONS:
<br /> L One I'ORM "B"shall be complete(,, for each Laulk for;all NEW PERMTIN,PERmn,cIJANGE.S, REMOVAIS nnd/1,c,,r anv
<br /> other TANK INfk`)RMA'I1ON CIL10SGR
<br /> 1 111is form should be completed by cither the PF.RMO'APPIJ(:ANFor the LOCAL AGENCY IINDERGROUND'J'ANK
<br /> INSPECII)R-
<br /> 3. Please type or print clearly all requested information.
<br /> I P
<br /> 4. Use a hard point-m-icing instrument,you are making 3 copies_
<br /> 'rOP OF FORM-*MARK ONLY ONE rnim,
<br /> 1. Mark an (X) in the box next to the itens that best describes the reason tile f0TM is being completed.
<br /> 2. Indicate the [)BA or Facility name where the tank is installed,
<br /> 1. ',I'ANK DF-SCRIVITON-COMPtEIM ALL rJEMS-IF UNKNOWN-M—)SPfX.7FY
<br /> A. Indicate owners tank 11) # - If there is a tank nuniber that is used by the owner, to identify the tank(ex,AB70,789),
<br /> B. Indicate the name of the company that manufactured the tank(ex.ACNIf."I'ANK MF(i.).
<br /> C. Indicate the year the tank was installed (ex. 1987).
<br /> 1). Indicate the tank capacity in gallons(ex.25,M)or 10,000 ctc.).
<br /> 11. 'EANK CONIENI'S
<br /> ,A1. If MO'rOR VEHICLE,17LJI:� .,check box I and complete items B& C.
<br /> 1 If not M0'I'OR VEHICLE,FUEL,check the appropriate box in section A and complete items I3& D.
<br /> B. Check the appropriate box.
<br /> C. Check,the type of%10'1'01C VEITICLI,FUL'I,(if box 1 is checked in A),
<br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C1A.S.#. (C.fiernical Abstract Service
<br /> number), if box I is Nar chucked in &
<br /> III. "IAN K CONS-I'RUCITON-MARK ONTIrl'T'lM ONLY IN JR)X A,B,C&D
<br /> 1. Check only one item in'I'Yllr.'r 0FSYS`I'FM,'I',ANK MA11,'RJAL, INFERIOR LINING and (."ORROSTON PRO'IE(7710N,
<br /> 2, If 011IFR, print in the spac,-,providcd
<br /> TV. PIPING INFO12M/V110N
<br /> 1. Circle A if above ground; circle U if undcrgroundg and circle both if applicable,
<br /> 2, If UNKNOWN, circle; or if 011TER,print in space provided.
<br /> 3. Indicate the LEAK 1NF11"(7 1('N system(s) used to comply with the monitoring requirement for the piping,
<br /> V. 'TANK LFAK DrUINXION
<br /> 1- Indicate the LEAK DE-11"(71,10N systern(s) used to comply with the monitoring requirements for the tank,
<br /> VL INFORMA"ON ON"I is PF.IUAANHN7I7LY C10SID IN PJACE
<br /> 1. E511MA11131) D/V11: J.ASI'USED-MONIII/YEAR(.January., 1988 or 01/88).
<br /> 2. E;,51`IMA'I'ED QUAN711-Y of.IIA7ARDOUS SUBS'I'ANCEI remaining in the tank(in Gallons).
<br /> 3, WAS MANK FILLED wriii �:Jreck Wes,or:No '.
<br /> Ai,pucwr MU%'I'SIGN AND D/VIE 1111I R)RM AS INDIIWIECC.
<br /> INS-I'RUCIION ICOR 1111,LOCAL AGUNCIEN
<br /> 'I'lin 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. 'I'he county and jurisdiction numbers are,predetermined and
<br /> can be obtained by calling the State Board (916)739-2411, 'I'lie facility number must be the same as shown in form "i\'% 'I'he
<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 /> 1"I'IS I-Iffl,RE.SPONSIBITTIN OF'I71E 1,00101,AGEN(I-11TA71'INSPE X'I'S'I 11E.,FAC 11,171Y ID VEIRIFly 111E
<br /> ACCURACY OF111F,INFORSINFIOM 7-OCAL A(UNCY IS R0STIONSIBI.11 FOR,nm COMPLE110N OP 17
<br /> '1A)CALAG ,NC'Y USE ONLY'TNI1)RMKIION BOX AND FOR FORWARDING ONE.R)RM*Are AND ASSOCINIED
<br /> FORM'B'(&)'F0 771E iU1J,(.)WING ADDRESS.
<br /> 91'AIE OF(WIFORINIA,
<br /> FIA1 ,I
<br /> 1�WA'ER flOARTa
<br /> PO.BOX 5Z7
<br /> 1?,,kRAMOIJFfl',CA%VM4
<br />
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