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<br /> IN9FRUC 11ONS FOR COMPI.MrITNG IF RM
<br /> GIINERAL 1N,';I7 UC`.l10NS-
<br /> 1, One FORM"B"shall be completed for each tank for all NEW P£ I" PER M1717CTIA NGIN, REMOVAUS and/or any
<br /> other TANS TNFOIthWl1ON CHANGE
<br /> 2, This form should be completed by either the ISI? IT APPLICAmr or the WC' .<AGENCY UN11E1ZGROUNT)TANK
<br /> ISI'E('POR-
<br /> 1 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 1711I)A'
<br /> L Marl, an (X) in the box next to the item that best describes the reason the form is being completed.
<br /> 2, Indicate the DB.,,\or Facility name where the tank is installed,
<br /> 1. TANK DF-S M71111TON-COMPLLTIT�All.r11JMS-IF UNKNOWN-SO SPWIFY
<br /> A, Indicate owners tank ID#-If there is a tank number that is used by the owner to identify the tank(ex.A]370789).
<br /> 13. Indicate the name of the company that manufactured the tank(ex.ACMF TANK MFG.),
<br /> C, Indicate the year the tank was installed(ex. 1987).
<br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.).
<br /> H. TANK CONIT3NIN
<br /> X L If MOTOR VEHICLE"FUEL,check box I and complete items B &C.
<br /> 2,If not MOTOR VEHICLEz FUEL,check the appropriate box in section A and complete items B. & D.
<br /> R Check the appropriate box.
<br /> C, Check the type of MOTOR VEIIICLI.-.FUEL(if box I is checked in A),
<br /> 1). Print the chemical name of the hazardous substance stored in the tank and the C.A,S,#. (Chermcal Abstract,Service
<br /> number),if box I is NOT checked in A.
<br /> 111. TANK C0N,1TMUC'17ON-MARK ONE ITEM ONLY IN BOX At B,C&D
<br /> I. Check only one item in T`YPE OF SYS 1'r3,M,TANK MNTT,.RIAL,INTERIOR LINING and CORROSION PRO TE�CnON.
<br /> 2, If OTITER,print in the space provided.
<br /> IV. PIPING INFORMNPION
<br /> L 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 /> 1 Indicate the LEAK DFFECTION system(s)used to comply with the monitoring requirement for the piping,
<br /> V. TANK LFAK DEN IX-11ON
<br /> 1. Indicate the LEAK DE-IT.C-FION system(s) used to comply with the monitoring requirements for the tank.
<br /> VI. INIDRMA71ION ONTANK PERMANTIMILY CIOSED IN PE
<br /> 1. ESTIMATED DA'I LAST USED-MONTII/YEAR(January, 1988 or,01/88).
<br /> 2, ESTIMATED QUANT`rrY of IIAZARI)OUS SUBS'I'ANCE remaining in the tank(in Gallons).
<br /> 3. LAVAS TANK,FILLEI) WITH INERT MATF,RIAL? Check'Yes'or'NO'.
<br /> APPLI(YiMr MUST SIGAN AND DXM7'n1E FORM AS INDKWPED.
<br /> INI;IRUC11ON FOR'n][11 LOCAL AGENCIES
<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", '111c
<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 prefer-,the State Board to assign the tank number,please leave it blank.
<br /> G'IS 11113 RESPONSIBILYff OF 71111 I AGENCY 17TATINSPFC17S 11113 FACIL171'Y'll)VIlpffly'111E
<br /> T
<br /> ACCURACY 0111111H,INIURMN.110N. 111H IA)CAL AGENCY IS RESPONSIBLE FOR 11IR COMPIX17ON OF 111E
<br /> *1,OCAL AGENCY U4'I1 ONLY"INFDIC IANITON BOX AND FOR FORWARDING ONE MRM"A"AND ASSOCIATED
<br /> MRM'B'(s)TIO-11111 IJP) NG ADDRESS.
<br /> STA111 OF CA11FORNIA
<br /> SrANTE WAIT R RESOURCPS CON'FROL BOARD
<br /> C/o 5mn11ps.
<br /> DATA PROCESSING CIWIER
<br /> P.O.13OX 527
<br /> PARAMOUNI',CA 90rM
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