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INSFRU(711ONS FOR COMPIHIING IT)RM*B' <br /> GENERAL INS`FRUC110NS-. <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMI'PS, PE.RM11701ANGE-S, REMOVAI.-S and/or any <br /> other TANK INFO VON CHANGE. <br /> 2. This form should be completed by either the PERMI'I'APHICANI'or the I,OCAL AGENCY UNDERGROUND TANK <br /> JNSPECFOR_ <br /> 3. Please type or print clearly all requested inforniation. <br /> 4. Use a hard point writing instmment. you are making 3 conies. <br /> TOP OF FORM: 'MARK ONLY ONE T1`EM" <br /> 1, 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 DF-SCRUYTION-COMPIJEITl ALI,rITDAS-IF UNKNOWN­SO SP1XJI?'Y <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <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. 1)87), <br /> 1). Indicate the tank capacity in gallons(ex.15,000 or 10,000 etc.), <br /> 11. TANK(X)NI1TX.1,S <br /> A. 1. If MOTOR VE.111CLE FUEL,check box I and complete items 13 &C. <br /> 2. If not MOTOR VEJIICLF FUEL,check the appropriate box in section A and complete items B & 1). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(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.#. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> HI. TANK C'ONSTRUCT'ION-MARK ONE ITEM ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in TYPE OF SYSTHIN1,17ANK MATERIAL,INTERIOR LINING and CORROSION PRarflcriON. <br /> 2. If OTIIER,print in the space provided. <br /> IV. PIPING INFORMNIION <br /> L Circle A if above 0-round; circle U if underground. and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if O' HER,print in space provided. <br /> 3. Indicate the LFAK DETEC-PION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLM.7t'llON <br /> L Indicate the LEAK DF'I`ECFlON system(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANENII.Y C1,0SED IN PIACI? <br /> 1. ESTIMNITiD DATE LAST'USED-MOVFII/YEAR(January, 1988 or 01ely). <br /> 2. ESTIMATED OUANPITY of HAZARDOUS SUBSIANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FIIkLJ?D WITH INFXl'MA'1T-1RIAL? Check 'Yes'or'NO'. <br /> APPI.ICAN'r MU,5rSl(;N AND DATI?171E FORM AS INDI(:NI'F.D. <br /> INS-MUCIION FOR`nIE 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 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 State Board to assign the tank number,please leave it blank. <br /> rr ISTTIE,RESI`ONSIBIIXTY OF'I1IE I.00AI.A(ilN(,Y'nIA7['INSPE(T.l.'S.111E FACH117YTO VERIFY'111E <br /> ACCURACY OFTHE INFORMN110N. 171E LOCAL AGENCY IS RRSPONSIBLE FOR'nIE COMP1.12.711ON OF'ITIE <br /> *LOCAL AGENCY USE ONLY'INFORMNnoN PDX AND FOR FORWARDING ONE FORM"A"AND A&SOCIAIUD <br /> FORM'B'(s)1101711? FOLLOWING ADDRFSS. <br /> S17XI`H OF CALIFORNIA <br /> F!' '17"WA`7—,R <br /> DATA PRO('-'F-%IN(; CINIT <br /> P.O.BOX 527 <br /> PARAMOUNT',(A 90723 <br />