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INSIRUCIIONS FOR COMPLEWING FORM 'B" <br />GENERAL INS .. C) <br />1. One PC) "i3" shall be completed for each tank for all NEW PERM17M PERMIT CHANGES, RFMOVALS and/or any <br />other TANK INFORMATION C:IIANGF. <br />2. This form should be completed by either the PERMyr APPLICJW or the IM..AL AGENCY UNDi? C'aROUND TAN <br />3. Please type or print clearly all requested information. <br />4. Use a hard paint writing instrument, you are making 3 copies.' <br />17OP OF ONLY ONE <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 where the tank is installed. <br />1. TANK DFSCRIVIION - COMPIPME AI.,I. TI w IF UNKNOWN- SO SPFACIFY <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. ACMME? TAN Mr(ix.). <br />C. Indicate the year the tank was installed (ex. 19£37). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />H. 'EANK CONTENIN <br />A. L If MC3"I`C)I2 V I ICLE> FUEL, check box 1 and complete items B & C. <br />2. If not MOTOR VEHICLE l[lE: L, check the appropriate box in section A and complete items 13 & D. <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEHICLE FUEL (if box I 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 />M. TANK C;ON,' UC CDN _ MARK ONE nIN ONLY IN . BOX A, 139 C: & D <br />1. Check only one item inTYPE OFSYSTEM, TAMC MATEIEJA,L, IN`I'ERIC)I2 LINING and CORROSION PROTECTION. <br />2. If OTHER, print in the space provided. <br />]PIPING INFORMAIION <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 LEAK DF TE ON system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DffI13GnON <br />1. Indicate the LEAK DEXEMON system(s) used to comply with the monitoring requirements for the tank. <br />IN14ORMAIION ON TANK PER ANIr 11,Y CLOSED IN PIACH <br />1.. ES11MATED DATE LAST USED - MONTII/YEAIC (January, 1988 or 01/85). <br />2. 17STIMATED QVAN PITY of HAZARDOUS SUBSTANCE: remaining in the tank (in Gallons). <br />3. WAS TANK FILLED wriii I Vpwrn-TRIAL? Check ''Yes` or 'NO', <br />APPLIC AAN 17 ` SIGN AND DA :? °I1ffl, r?ORM AS <br />UC'.I7ON FOR711-113 LOCAL AGFN ISS <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 />IT IS IIIE RESPONS11111117Y OF 17111 I.C)C'AL AC11: C"Y THS17 INSPE I a 11111 FACILT17Y TO VERIFY17113 <br />ACCURACY C)F TIIE, 'I.10N. 7111E IA3CAL AGENCY Y IS sPONSIBI,Ii FC)IE ,nm C:C) PL I`IC)N 01111113 <br />*LOCAL AGENCY IJSff: ONLY" INFORMATION BOX AND MR FORWARDING ONE I `A" D ASSC)CINITT,I) <br />FORM 'B'(s) C3 ADDRESS. <br />,FATE C21rI.JMI IA <br />C:/C) s.'w.i:r I�-P.S4 <br />DATA PROCIiSSING CEIVIUR <br />P.O. BOX 527 <br />PARAMOUNT, CA <br />a <br />