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<br /> TN;�__TI2!)C:.I1C)Nxs 13 C", } 3PI,Iz"1"Tie1C:a 1�C) T W e++,
<br /> GENERAL
<br /> I. one,FORM RM "B"shall tic cnmplc3c d fc,. t a£21c fir at, E"V"' , . .t, B T ,PF.R r1'€I1ANC:TI AN„ REMOVAIS and/or any
<br /> cnher`YA,A'f INIr()RMIV110C"1IAN(Jil.
<br /> 1 This )rm ;.aorto. be ..onipJetcd by -ith,i ..a=c the L0Q%LAGT!N(7Y UNDERGROILTNI)TANK
<br /> 3. Plyax;c typ, or prin', cleus-ly all reclusst. ;„Eformat~ion,
<br /> 4. Use a har,>point writing mstrumc t,yoi are making 3 copies_
<br /> TOP t)I.I I I:"MARK ONIA 0t°31: (n '
<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 wher tc tank is installed.
<br /> 1. TANK DESC".I2IPC1f)N-C()MPL1T)IrE All,TITS ,S,,a.Il,UNKNOWN w St�Sem,Fy
<br /> A. Indicate owners tank IT:) M If there is a s;:ank number that is used by the owner to identify the tank(ex.ATB70789).
<br /> Iia. Indicate ,hc, manic of tire;corrapany that ,cufactureci the tank(cx.AG I`TAN F1(3.),
<br /> C, Irteltxats the year the tank was instsallcc (ex, 1987),
<br /> 11 Inds atu the tangy calracily in fstilor; ( V sS r) , or 10,W)ctc.),
<br /> I7, TANK C:"G71Y'IE I
<br /> A. 1. V1111C LI" F(JEL, check box I and complete items B& C,
<br /> 2. If not tC:)'i'OR VEHICLE FULL,check the;appropriate box in section A and complete items B &D,
<br /> LB. Check the:appropriate box.
<br /> C. ("beck the type of MOTOR VEHICLE,LE,FUF11,(if boa I is checked in A).
<br /> 1). Prinz disc F ha;tnical marred of the hazardous substance stored fit the tank and the C.A,S. . (Chemical Abstract Service
<br /> ntssrtber), sf box 'I is NOT checked in A.
<br /> TIT. TANK C0N 1'RLJC;'I10N. MARK ONE rJ TN ONLY IN BOX A,IB,("„&T)
<br /> 1_ Check only one ire rn inTYPE C)1 S'a;°1'I '?M,'t:AiNK MA 11"RIA L,INTERIOR ERIOR LINING and CORROSION PRO'TFC'F1O N_
<br /> 2. If t""1'TlEI ,print in Lire sparse provided.
<br /> XV. PIPING INl°i) t . '1 t)d
<br /> 1. Circle A if above ground; circle U if underground; and circle truth if applicable.
<br /> 2. If UNKNOWN, circle, or if C!"l H €1,y print in space provided.
<br /> 3. Indicate the LF-AK DE,"TT,,C'1`ION system(:)used to comply with the r ionitoring requirement for the piping
<br /> V. TANK 11I)VIIX7110
<br /> 1. Indicate the LEAK [)t!a I ,(7110N systcnt(s) used to conrplywith the monitoring requirementsfor the tank,
<br /> VL I,N[4') A.IIO O 'IA K..1'IgRMAN[aNrl,I,Y('I.,(.)SI:;1)I PI,aA(lI
<br /> L ES'JIMAITED DATE I.A,1,3l'USED-MON I`11/Y Ail (January, 1.988 or 01/88).
<br /> 2. lei l`;M.$ I',E) CyL,'FtNTT ry of IIt1ZAttDOU'S SU BIs'l'RNC E rems;ning it)the t=ank (ids Gallons),
<br /> 3, WAS TANK FILLED WITH IN1f1C']'NIA"IERIAL?Check 'Yes' or'NO'
<br /> AIsPII A I' U I'SI(nN AND 1)KIE'111E FORM AS I I)KA'113I).
<br /> I SI"IxC1('170N W) `1"111?LOCAL ACxENC:I-S
<br /> The; state underground storage tank identificaaiion number is composed of the two digit county number,the three digit jurisdiction
<br /> number, the six digit facility number and the sir;digit tank number, The county and jurisdiction nt tilt>ers are predetermined;and
<br /> can be obtained by calfing the State Board (916)739-2,,121. The facility number must Bre the same as shown in foartrr "A"...The
<br /> tank number may be assigned by the kcal agcncy; however, this number must be numerical and cannot:contain an alphabet. If
<br /> the local rage,ncy,prefers the Mate Board to assign the tank number,please leave:it bland.
<br /> T'IS'11111 RESPONSIBUXIT OF 171E LOCAL AGENCY 1' AT INSPIr,C""IN-111E FACIT1.TrY TO VERIFY11111
<br /> AC'C' T ('Y()F'IT ili IN1I'C)IlL "I1t)N. `17171 LOCAL AGENCY Y I T(TI.SPONS[BLE TSI('1117; '(7 1:13110 OF WE
<br /> 'T. CAL AGENCY UxS13 ONLY'IidT°ORMNn BOX AND 1R,IX)RWARDING ONE FOR "A"AND Ax's:. KII?L)
<br /> ICOR @Il"(s)T0'I.T1E It0I.I)OWI G ADDRESS.
<br /> ri'AIT OF(W JF't)RNIA
<br /> I)A` AIa1C()C'IlSSINta C'If IT,1C
<br /> Y,.(Jc]K)X 527
<br /> PARAMOUNT, (A e 1
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