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GENERAL IN'�;FRU(711ONS- <br /> 1.. One FORM"B"shall be completed for each tank for all NEW IEEE I'S,PERmrr CHANGES, I2 E OVAl and/or any <br /> other' A K INFORMN110N CHANGE. <br /> 2 This fora should be completed by either the PERMrF APPI.I I'or the LO(.'AGENCY UNDERGROUND TANK <br /> I SI', .I'C)I. <br /> . Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF I 'MARK ONLY ONE 1 `I= w <br /> 1. Mark an (rC) 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 /> L TANK DI SCIPTIO -COMPLISIM ALL r1`E S-IF UNKNOWN-SO SPECIFY <br /> A. Indicate o%vners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.A1370749). <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. 1947). <br /> D� Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. TANK C 1 "ITEM S <br /> A: 1. If MOTOR VEHICLE PU EL,check box I and complete items E3&C. <br /> 2. If not MOTOR VEHICLE 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 IVCfJ'rOR VEMICI.,E IQ"t1EL(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 NOT checked in A. <br /> 111. `PANIC C ON UCC'10 -MARK ONE ITEMONLY IN BOX A,ii,C&I) <br /> 1. Check only one item in TYPE OF S'YS rE314I,°I"ANK MATERIAL,WE'ERIOR LINING and CORROSION PRC rr,.C7T°ON`, <br /> 2. If GIIIER,print in the space provided. <br /> IV. PIPING INPORMA'nON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable, <br /> 2. If UNKNOWN,circle;or if OTIIER,print in space provided. <br /> ' 3. Indicate the LIAR E)E'I"E C:'riON systern(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK I)IrI'1 ®.I1O <br /> 1. Indicate the LEAK 1)E7I7:Cr It7N system(s) used to comply with the monitoring requirements for the tank. <br /> 1, r.mimAIEM DATE LAST USED-MO I/YE:AIt(January, 1.9£34 or 01/44). <br /> 2, i.—snAtA`I'E I.3 QuAIVE'CrY of ElAVAE2DOUS SUFK',.'I°ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INE Irr MA':I'IE L? Check 'Yes'or'NO'. <br /> APPLICANT US SICK AND I)AI13'XIII FORM AAS I )I" I <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". '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 /> I"I'IS 7IIIE P(.) SFBH t°I'Y OF 71111 LOCALAGENCY MINFINSPBM*11113 FAC; "I TO VERIFIVITIE <br /> AC('URACY C F THE INFORMN110N. THE IOCAL A ENC"Y IS RESPONSIBLE FOR7111133 COMP1.11110N OF"I`EIE <br /> *LOCAL AGENCY USE ONLY"INFORUNIION BOX AND FOR FORWARDING ONE IHC3 "A"AND ASSOCIATED <br /> fir IIE WAVER RESOURCES C O C)IA BOARD <br /> C/O 5. ".71,3?P.S, <br /> P,O.BOX 527 <br /> PARAMOUNT,CA <br />