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IN91RUC11OMS FOR COMPIZ10,FORM'Ir <br /> GENERAL INSTRUCTIONS: <br /> l- One FORM "B" shall be completed for each tank for all NEW PERmn.N, PERMrr 01ANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCALAGENCYUNDERGROUNDTANK <br /> INSPE(7170R. <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 rIT2A' <br /> L Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> -)'--_;,Indicate the DBi\or Facility name where the tank is installed. <br /> 1. TANK DF.SCRIVIION-COMPI111E AII,T113MS-]F UNKNOWN-SO SPECIFY <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 /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> 11. TANK CX)MMININs <br /> A. 1. If MOTOR VEIIICLI:11 FUEL,check box 1 and complete items B &C. <br /> 2. If not MOTOR VEIIICLF*FUEL,check the appropriate box in section A and complete items B& D. <br /> 13. 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 1 is NOT checked in A. <br /> 111- TANK CON',1;'.I7RucnON-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM;TANK MATERIAL, DZIERIOR LINING and CORROSION PROTU,'Cl`ION. <br /> 1 If OTHER,print in the space provided. <br /> IV, PIPING INFORMATION <br /> 1. 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 /> 3. Indicate the I,LAK D14,113CTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUIV(711ON <br /> 1. Indicate the LEAK DM- 'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ONTANK PERMANEIVILY CLOSED IN PLACE <br /> 1. EsnMNIT.D DATE,'LAST USED-MONTII/YI.-AR(January, 1988or01/88). <br /> 2. 0511MATED QUAxrrry of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATFRIAL? Check'Yes'or'NO'. <br /> APPI.I(YiNr MUST'SIGN AND DA113 MIE 1,K)RM AS INDICATED. <br /> INS IRUC17ION FOR'ITIE LOCAL AGENCTES <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 /> TT IS 11111 RESPONSIBELTI'Y OF TETE IA)CAL AGENCY IIIAT INSPICIS11111 FACUXIT TO VERIFT'ITHI <br /> ACCURACY OF'IIIE INFORMA'110N. 111H IOCAL AGENCY IS RESPONSIBLE FOR IIEF: COMPI.ITIION OF 11113 <br /> *LOCAL AGENCY USE ONLY'INFORMNIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOMIED <br /> FORM 'B'(s)TO-11111 FOLLOWING ADDRI!%. <br /> ST)VIT,OF CAIJFORNIA <br /> S`DVIE WAITR RIISOURCES CONI'ROL BOARD <br /> C/O&W.E-F-P.S. <br /> DATA PROCESSING CENIT.R <br /> P.O., BOX 527 <br /> PARAMOUNF,CA 90723 <br />