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INSTRUCTIONS FOR COMPII?'17NG FORM '11' <br /> GENERAL 1N91'RU`CF[ONS- <br /> I <br /> I. One FORM"B"shall be completed for each lank for all NFW PERMITS, PERMIT CHANGES, REMOVAI.-S and/or any <br /> other TANK INFORMN110N CTIANGF_ <br /> 1 "This form should be completed by either the PERMIT APPI1CANI'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <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 FIEM' <br /> 1. Mark an (X)in the box next to the item that best describe-,the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DESCRIV11ON-COMPLU17 All.MWS-IF UNKNOWN­SO SPIRI JIN <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 /> 1). Indicate the tank capacity in gallons(ex.15,(X0 or 10,00.0 etc.). <br /> H. TANK(X)MENIN <br /> A. 1. If MOTOR VEIIICIJI� FUEL, check box 1 and complete items B&C. <br /> 2. If not MOTOR VFIIICI1. 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 VEHICLE 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 NO'I'cbcckcd in A. <br /> 111. TANK CONSTRUC`IION-MARK oNjL ri'Em ONLY IN IX)X,A,B,C&1) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTIliclION. <br /> 1 If OTHER, print in the space provided. <br /> IV. PIPING IM?0RMA`I'ION <br /> 1. Circle A if above ground; circle U if underground: and circle both if applicable. <br /> 2. If UNKNOWN,circle: or if O'HIER, print in space provided. <br /> 3. indicate the LEAK DFTEC]_ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLMCPION <br /> 1. Indicate the LEAK DETECTION systern(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFX)RMA'nON ON TANK PERMANEM11,Y CLOSED IN PLACE <br /> L F.STIMA_I`J..,.D DATE I.AS-FUSED-MONFII/YEAR (January, 1988 or 01/94 <br /> 2. ESTIMATED QUAN7F1TY of HAZARDOUS SUBS I'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK Fltff.�D WH II IV`1RT.M—A'ITRIAL? Check 'Yes'or'NO'. <br /> APPIlCANr musr SIGN AND DATE'ITIE FORM AS <br /> IN(;l[RU(7I1ON FOR nJE LOCAL AGENCTE-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 lank 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 State Board to assign the tank-number,please leave it blank. <br /> rr IS'1IIE RHSPONSIBILrI'Y 014111E LOCAL AGINCY TI1A`1'INSPW_I'8111E FACII.XtY'TO VERIFY"111E <br /> ACCURACY OFTIIE INFORMYVIION. TIIE I.,OCAL AGENCY IS RESPONSIBLE?FOR ITIE COMP1lr11ON 01.111E <br /> *LO(:AI,AGENCY USE ONLY"INFORMA11ON BOX AND FOR FORWARDING ONE FORM"A*AND ASS()CIA7VD <br /> FORM"B"(s)1-0-1111z FOLLOWING ADDRaSS. <br /> ` I'JVJE OF CALIFORNIA <br /> SPA"T"WA�'IER CAONTROI, )ARI) <br /> DATA PROCESSING CI-NI*ER <br /> P.O.BOX 527 <br /> PARAMOUNT', CA 9(YM <br />