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INSLRUCPIONS FOR COMPU TING FORM'B' <br /> GENERAL INSIRUC110NS: <br /> 1. One FORM "B" shall be completed for each tank for all N13W PERMITS,PERMIT'(:IIANGFS, REMOVAIS and/or any <br /> other TANK INFORMATION CIIANGC <br /> 2. 'This form should be completed by either the PERMIT'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 are making 3 copies. <br /> TOP OF FORM:'MARK ONLY ONE ITEM' <br /> 1. Mark an (X)in the boi next to the item that best describes the reason the form is being com�leted. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. 'TANK DF_SCRIPIION-C OMPLET?AL1.rrFMS-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.ACM13 TANK MPG.), <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 /> It. TANK CONTEMN <br /> A. 1. If MOTOR VEHICLE MEL, check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE,FURL,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 I is NOT checked in A. <br /> III. TANK CXINSTRUCTION-MARK ONE I119N ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <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'IIIF.R,print in space provided. <br /> 3. Indicate the LEAK DSIEC"PION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMIVIION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DA'T'E LAST USED- MONT'll/YFAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MAT17RIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE'THE FORM AS INDICA'110. <br /> INSTRUCTION FOR'IIIE 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 171E RESPONSIBILITY OF TME LOCAL AGENCY 1'IIAT INSPEC N 17IF_FACILITY TO VERIY TIIE <br /> ACCURACY OF TITF.INFORMAITON. THE LOCAL.AGENCY IS RESPONSIBLE FOR TILE COMPLETION OF 1ITE <br /> 'IOCAL AGENCY USE ONLY"INFORMATION BOX AND POR FORWARDING ONE FORM 'A'AND ASSOCIATED <br /> FORM'B'(s)TO 111E FOLLOWING ADDRESS. <br /> STAIE OF CALIFORNIA <br /> STATE WATER RESOURCES CbM'ROL BOARD <br /> C/O&W.EEP.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9UM <br /> 0 0 <br />