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INSIRUCIIONS FOR COMPLETING FORM"B' <br /> GENERAL.INSIRUCIIONS: <br /> L One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMrl'CILANGPS, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <br /> INSPECTOR- <br /> 3. <br /> NSPEC TOR- <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 IIP_M' <br /> 1. Mark an (X) in the boz 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 /> L 'TANK DESCRIPTION-COMPLETE AI.:L MEMS-IF UNKNOWN-SO SPECIFY <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.ACME TANK MPG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.2$,000 or 10,000 etc.). <br /> 11. 'TANK C ONITNIS <br /> A. I. If MOTOR VEIIICLE FUEL,check box I and complete items B& C. <br /> 2. If not MOTOR VEHICLE 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 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 /> number), if box 1 is NOT checked in A. <br /> 1B. TANK CONSIRUCIION-MARK ONE TPEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROT'F,CIION. <br /> 2. If OTHER, print in the space provided. <br /> IV. 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 O'TEEER, print in space provided. <br /> 3. Indicate the LEAK DEPECIION systems) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEI'ECEION <br /> 1. Indicate the LEAK DETF.CIION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY(,'IASED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WIT'IE INERT NITRIAL? Check 'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DATE'IIB?FORM AS INDICtI IID. <br /> IN.S"IRU(TION POR TILE 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 (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 TILE RESPONSIBILITY Y OF TIIE LOCAL AGENCY'IIIAT INSPECIN TILE FACILITY TO VERIFY TTIP. <br /> ACCURACY OP TILE INFORMATION. 'LIR:LOCAL AGENCY IS RESPONSIBLE FOR TELE COMPLETION OF TIB? <br /> "LOCAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM 'A'AND ASSOCIATED <br /> FORM 'B'(s)-FO TILE FOLLOWING ADDRESS. <br /> STA'I'D OF CALIFORNIA <br /> SFXIE WATER RESOURCES CONTROL.,BOARD <br /> C/O SW.EF P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527- <br /> PARAMOUNT,CA 90M <br /> 0 0 <br />