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<br />IN,4;1'RUCITONS IX)R COMPLETING FORM '141
<br />GENERAL s I'RUC .I' 0,p[S.
<br />1. One FORM "B" shall be completed for each tank for all NEW PERMM,, PH.RivIrr CIA N GFS, RFMOV IS and/or any
<br />otherTANK I FC)1 A"1'IC) t C:HANGU
<br />2. This form should be complcted by either the PER r1" APP N`I' or the LOCAL AGENCY UNDERGROUND'I"ANK
<br />JN,SP 1'C 1t.
<br />3, please tyke or print etcarly all recraaested inforntation.
<br />4. Use It har€a. saint," +hint- ima timew,you are rn aking 3 copies.
<br />TOP OF FORM: 'MARK ONLY ONE YIEM'
<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 I)BA,or,Padlity,name cohere the tank is installed.
<br />I. TAMC DF-SC:RIV11 N - C O ' IT! All, ? S - IF UNKNOWN - SPMff T
<br />A. Indicate owners tank IU ff - If there is a tank number that is used by the owner to identify the tank (ex. A B70789).
<br />B. Indicate the name of the corafnmy that manufactured the tank. (ex. ACMF:'IANK MFG.).
<br />C. Indicate the year the tank was installed (ex. 1987),
<br />I). Indicate the tank capacity in gallons (ex. 2.5,000 or 10,W0 etc,).
<br />H. TANK (X)NITIMPS
<br />A 1. If MOTOR Vf.,Jl1C'IX FUEL, check box 1 and complete items B & C.
<br />2, If not mcyrm vEmICI,i, FUEL, check the appropriate box in section A and complete items IB & I:).
<br />B. Check the appropriate box.
<br />C. Check the type of MOTOR Vl:?IJIC'L E 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 />nurnber), if box 1. is NO T` checked in A.
<br />III. TANK C O STRUC11) - MARK ONE TI"I7. (C)NLY IN PDX. Vii, 11, C & I)
<br />1. Check only one item in T PE OF SY S'I EM, TANK MATERIAL, ]INFERIOR LINING and CORROSION 1'ROTIBC 1:"100.
<br />1 If OTHER, print in the space provided.
<br />1. Circle A if above ground; circle U if underground, and circle bath if applicable.
<br />2. If UNKNOWN, circle, or if OTHER, print in space provided,
<br />3. Indicate the LEAK DL`TE?C".l'IC)N system(s) used to comply with the monitoring requirement for the piping<
<br />V. TANK LMK Dill, WX'ITON
<br />1. Indicate the LEAK DEFECTION systent(s) used to comply with the monitoring requirements for the tank.
<br />VI. INFOR A"IION ON.' ANT I ERMA UN M C3,A)SED IN PIACM
<br />1. aSTIi ATI l) i?! FE, I.AS-F USED - N447;NFII/Y£'AR (January, 1988 or 01188).
<br />2. ES`FIMATF) QUA:NTrry of HAZARDOUS SUBSTANCE remaining in the tank (€n Gallons).
<br />3. WAS TANK I'II<LIFI) WII'll I:mrC°.IZ,r MA`ITRIAI.,7 Check 'Yes' or 'NO'.
<br />APPI.IC ANT MUSI'SIGN AND DX1` 1 °1711? 1URM alb I DWA
<br />' .. UCeI1O FDR 17111 IA)CAL AGENCI1kS
<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 number,$ 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 contpin.an alphabet. If
<br />the local agency prefers the State Board to assign the tank number, please leave it blank.
<br />rr Is innos Ns11111.11Y OF 11111 IDCAL AGINCY Tl-1K..l` 1NSP FIS "I IIA FAC',111'I`C) VERWY 311E
<br />ACCURACY O °:11113 IM70RMXIION. 17113 LOCAL a1C1ENCY IS RESPONSIBLE FOR TI1E COMPIEPION OF 711
<br />'LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR IZORWARDING ONE FO 'A" AND a.S,SC)CAIAT D ;
<br />1 'B'(s) 1`7 111131 I'C LLO I G ADDRFSS.
<br />, All! OF CATIFORNIA
<br />41
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<br />d" ,
<br />111,
<br />P.O. BOX 527
<br />IFA. A O I', CA 90M
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