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INSTRUCTIONS ICOR COMPL FFING E "I3" • <br /> GENERAL MSTRUCITONS: <br /> I. One FORM"Ii"shall be completed for each tank for all NEW PERMI75,PERMIT CHANGES, RF.MOVAI.S and/or any <br /> other TANK INFORMATION CIIANGFL <br /> 2. "Phis form should be completed by either the PERMTr APPI ICANr or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEClrOR <br /> 3. 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 111?M' <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 /> I. 'TANK DF.SCRIPITON-COMPt.FHF,ALL rII?MS-IP UNKNOWN-SO SPMTFY <br /> A. Indicate owners too ID# -If there is a tank number that is used by the owner to identify the tank (ex.AI370789). <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.25,00 or 10,000 etc.). <br /> H. TANK C`)ONTF,NIN <br /> A. 1.. If MOTOR VEHICLE FU11L,check box I and complete items B& C. <br /> 2.If not MOTOR VI IIICL.E FUEL,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE E FUEI,(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 /> III. TANK CONSTRUCTION-MARK ONEi rI1 M ONLY IN BOX A,II,C&D <br /> 1.. Check only one item in TYPE OF`SYSTEM,"TANK MATERIAL,, INTERIOR LINING and CORROSION PROTF...('IION. <br /> 2. If OTHER,print in the space provided. <br /> TV. 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 OT)IFR,print in space provided. <br /> 3. Indicate the LEAK DE' EC'TION systems)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DMT7.CI1ON <br /> 1. Indicate the LEAK DETE(] ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENFLY C11OSED IN PIACE <br /> 1. ESTIMATED DATE LAST USED-MONTE3/YEAR(January, 1988 or 01/88). <br /> 2. ESI'IMATEi) QUAN'TI'TY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTTLI INERT M.A'TERIAL?-Check'Yes'or'NO'. <br /> APPLICANT'MUST SIGN AND DA FE THE FORM AS INDWATED. <br /> INS'T'RUCTION FOR171111?LOCAL,AGENCIES <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(91.6)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 THE RFSPONSIBIIZI'Y OF THE LOCAI,AGFNCY THAT INSPM. - I7TE FA(:ILM'1'O VERIFY TIII? <br /> ACCURA('Y OF TIHI INFORMATION. 17IE L.O(W,AGENCY IS RESPONSIBLE FOR 17113,COMPtHnON OF'I7II1 <br /> 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM'B"(s)TO 111E FOLLOWING ADDRESS. <br /> SE FE OF CA1114ORNIA <br /> STATE WA ER RESOURCES CONTROL BOARD <br /> C/O S.W.LiF P.S. <br /> BATA PROC:F;SSING C NFER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />