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INSTRUCTIONS FOR COMPLEPING FORM"B" <br /> GENERAL INSFRUCFTONS: <br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS,PFRMIr CIIANGES, RE?MOVAI S and/or any <br /> other TANK INFORMNITON CHANGE <br /> 2. this form should be completed by either the PERMIP APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you am making 3 copies. <br /> TOP OIt FORM: 'MARK ONLY ONE ITEM' <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 DFSCRFPITON-COMPLUTI-4 ALI.ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate tnvners tank N # -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 MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). <br /> IL TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE,FUEL, check box 1 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 /> Ill. TANK CONSTRUCITON-MARK ONE rrEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OI'SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If 0111ER,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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DEII?CTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DILFECTION <br /> 1. Indicate the LEAK DEPECDON system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED -MO1,T71/YEAR(January, 1988 or 01/88). <br /> 2. ESITMNIED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANTO FILLED WITII INERT MXFFRIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA'I E TILE FORM A.S INDICA'ITD. <br /> INSTRUCTION FOR TT IE 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 am 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'ITiE RESPONSIBBIEY OF TTIE Lo(%AL AGENCY TTIAT LNSI'E(,TS THE FACLLITY'110 VERIFY TI1E <br /> ACCURACY OF TILE INFORMATION. 11iE LOCAL AGENCY IS RESPONSIBLE FOR TTIE COMPLETION OF TIB? <br /> "IACAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONF.FORM•A•AND ASSOCIATED <br /> FORM"1E"(s)'IO 171E FOLLOWING ADDRESS. <br /> SPATT', OF CALIFORNIA <br /> SPATE WATER RESOURCES CONTROL HOARD I <br /> C/o SW.EEP.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90M <br />