|
I SIT UC"1TONS IX)R C"OMPL 7 G FO "I r
<br />GENERAL I ',1n'ICL ("11ON%-
<br />1. One FORNI "B" shall he completed for each tank for all NEW PBRMI I z, PlMmrr C;1_. G S, REMOVAL acid/or any
<br />other TAN iNFO A"I1C)N C,°1 F_
<br />2. This forsaa should be completed by either the P 11' PLICA "or the 1A) ` I, AGENCY UNI7II 2C1 UND IAN
<br />I SPIT..C"PO ..
<br />3. Please type or print clearly all requested information.
<br />d. Use a hard point writing instrument, you are making 3 copies.
<br />7'00 OF FORM: : " R ONLY dNE ` `79W
<br />1. Mark an ()C) in the box next to the item that best describes the reason the form is being completed.
<br />2. Indicate the DBA or zacility name where the tank is installed,
<br />I. TANK 1312SCRWITON- C1OMP1.I7E All, I't S -1Ir UNKNOWN - SO SPI 11'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. 1987).
<br />I), indicate the tank capacity in gallons (ex. 2.5,(M or 10,000 etc.).
<br />H. TANK CONTENIN
<br />A. 1, If MOTOR VI IIIC,LE FUEL, check box 1 and complete items B & C.
<br />1 If not Mt:)'IOR VEHICLE 1'i;`EL, check the appropriate box in section A and complete items B & D.
<br />B. Check the appropriate box.
<br />C. Check the type of MOTC.)It VEHIICI,T; FUEL. (if box 1. is checked in tA).
<br />1), Print the chemical name of the hazardous substance stored in the tank and the £';.A..5<#. (Chemical Abstract Service
<br />numbs r), if box 2 is NOT checked in A.
<br />III. TANK CC)IsIS'I.I UG11C)Pt - MARK ONE rl'EM ONLY INWA IN'aA, B, C & I)
<br />1. Check only one item in "IYPE' C)I9 SXSTF M, TANK MA"I"INCtAL, INTERIOR LINING and CORROSION I'ILt TE"C CION.
<br />2. If OTHER, print in the space provided.
<br />Ito. PIPING IMZO 'I1C)
<br />1. Circle A if above ground; circle I1 if underground; and circle both if applicable.
<br />2. If UNKNOWN, circle: or if C)"I'HER, print in space provided.
<br />3. Indicate the I.,EAK DETECTION system(s) used to comply with the monitoring requirement for the piping.
<br />V. TANK LEAK DF X,"I°IC)bi
<br />1. Indicate the LEAK i7F,,rElC r ON systerti(s) used to comply with the monitoring requirements foo- the tank.
<br />VL 1 O ATION ONTANK PER ANI<PC"11,Y C°LO!SED IN PlACE
<br />I. ES°7TMNI"T:I) DATE I,A,51' USI?i) - MONI I:`II/°Yf?AR (January, 1988.or 01/88).
<br />2. F-STIMATED C?(:IAN`. ITt' of HAZARDOUS Si"JBSI'ANC;F remaining; in the tank (in Gallons).
<br />3. WAS TANK FILLED ED W11 1 IR'EK , 'I`ER AI.,I Check ''Yes' or 'IAC)'.
<br />APPIICAMr MU517 SIGN AND I)A'n' `ITIE MRM, AS INDICN17FD.
<br />INS'PRUC11ON FOR 'I'IIE.? LO(Yd, AGENC"III-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 />ri, IS mE IttIS"PL)NSI:BU IrY C) x'1'9-194 I A(:PINC Y THA I" i SPIN7.1S `ITI'I? F C:IlXrY TO VE Iff '11111
<br />ACCURACY OF'I71E INFC)IC I10N. 'Hill L(X:AL AGENCY IS RESPONSWIE PX)R °IIIE COMP11.1110N OF 11113
<br />"LOCAL C'AL AGE CUSE ONLY" INFORMA17ON BOX AND FOR 11WORWARDING ONE FOR °A" AND ASSOCIATED
<br />FORM 'B'(s) TO '11113 FOLI C1I) 7t"S,S,
<br />rNllf OF CATIFORNIA
<br />DATA P OCE-SSING CMNI1-
<br />P.O. BOX 527
<br />PARAMOUNT', UNT', CIA
<br />
|