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1NF UC'11ONS FOR C OMPL a 3N G I Il"
<br /> t"EINE RAU.1N,1;I`I UU:NONISt
<br /> L One FORM"B" shall be completed for each tank for all M,,W PUR I s PIRMrFCI1ANGES, REMO AUS and/or any
<br /> " other T NF I7 IION C I GEC Y
<br /> 2. This form should he completed day either the F MYI' pi ANt1'or the ,C)C'AIE ASI N 1' 1:RGRO I'AN
<br /> INSI$ T)C
<br /> 3, Please tyke or print clearly all requested information.
<br /> 4. Use a hard point meriting instrument,you are max ng`3 cops cs.
<br /> ""op OF PORM.'MARK ONLY ONE Clot
<br /> 1, Mark an (X) in the box next to the iterin that best describes the reason the form is being complc&ed.
<br /> Indicate the DBA or Facility name wbere the:tank is installed,
<br /> _ TANK 3I? RIF)IONT-«COMPLUrE All, .EMS- -'UNKNOWN fa"
<br /> A. Indicate owners tank ID #- If there is a_tsank number that is used by the owner to Identify the tank(ex.AB70�89).
<br /> I?. Indicate the name of the company that r an afsacturcd the tank(ex.C:CyrfP'ZAN FFG,),
<br /> C;. Indicate the Vicar the tank was installed,(ex. 1€87).
<br /> I). Indicate the.tank capacity in gallons(ex.25,000 or 10,0 00 etc,),
<br /> 11. TANK CONTENI'S
<br /> A. 1, If MOTOR VEHICLE F t;Itk,check box land complete stars 1I & C.
<br /> .if not MOTOR adIICi,E FufiL,aleck the appropriate b€rx in s ;°tion A and complete iteral 1:I& D7
<br /> B. Check the appropriate ate box.
<br /> '. Check the type of MOTOR VEHICLE,FL,t1 I (if box 1 is checked in.k). ice
<br /> S;' Print the chemical mare of the hazardous substance stared in the tank and the:C_A.S. .(Chemical Abstract af;s:v
<br /> number),if box 1 is NOT checked in A,
<br /> III, 'l.ANK C0N,1".1'RU ;'IO ..MARK ONE rI-EM ONLY IN BO IF,C:&1)
<br /> L Check only one item mTYPF._OF SYSTE C,`1ANK NIA'IE'RIAL, LN'113RIOR LINING and CORROSION I'1?.(3"iE'(7F'0N.
<br /> 2, If Ct'I"tiEk,Print in the'space provided,
<br /> IV. PIPING INFORMA11ON
<br /> 1. Circle A if above ground;circle'U if underground) and circle both if applicablc.
<br /> 2. If UNKNOWN,circle or if OTHER,print in space provided,
<br /> . Indicate,the LEAK t1 'I"I..C'11ONs system(s)used to comply with the monitoring requirement for the;piping.
<br /> V. TANK L a IC L TgEC FIf3td
<br /> 1. Indicate the LAK ISI`7I,C,I"100 system(s) used to comply with the monitoring requirements for the tank.
<br /> V1. INFORSIMHON,ON TANK PERNIANEIVIIN CLOSIFD ITS PLACE
<br /> 1.. I:S I`hMATED DATE LAST USED-MONTI-II/YFA (January; 1988 or 01/88).
<br /> 1 E TINIATI.-I5 Q N17I Y of III ZAkt,DOUS SUBSTANCE remaining in the tank (in cjallans).
<br /> WASTANK FILLED;W1111 INTWr A17E:' IAL? Check'Yes'or'N6'.
<br /> INSfi'1LU(N. £3 8 FORum LocAit,A(mNci
<br /> The state underground storage tank identification number is composed of the tsvo digit county number,the three digit:jurisdiction
<br /> number,the six digit facility number and the six di-it tank number, The county and jurisdiction numbers are predetermined and
<br /> can be obtained by calling the Stats Board (91ti)73tt-2421, `I`he facility number must be the same as shown in form "A"° The
<br /> tank number may be assigned by the kcal agency-,.however,this number must be numerical land cannot contain an alphabet, �If
<br /> the local agency prefers the State Board to assign tits tank number,please leave it blank.
<br /> I''1S T1IF RESi"CSNISIIIII: "I ''()It IE I (" C; tt+FC"lf"L'11 'INdSPI!(.'1,S't"III: aAC11,171'Y'11)VERIFY 11IIt
<br /> AOCURA('Y OF TTIt3 INFORMKIION, THE 1 X AGENC Y IS RES ONSI 3I 'FO 'f 111 C OMPLI-5r1I N 01"111E,
<br /> "113cAL AoENCY USE ONLY* Ian) K].10Ni:BOX AND FOR 1fC)1C'# A3tDING ONE FORM*A'AN13 ASSOCIATED
<br /> IAC) -B%s)T 3 111E IXAJOWING ADDRII&S.
<br /> 51WIT'OFC'A111D C 11S
<br /> C/o S.' .I np.'
<br /> 13NI'A PROC13SSING CENI
<br /> '.G .BOX S21
<br /> P Mt3UNI-,CA 90723,`
<br /> off :
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