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n <br /> INSTRUCTIONS FOR COMPLETING 104'B' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PBRMPIS,PBRWr,CHANGFS;-.RI?MOVAIS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. 'Phis form should be completed by either the PER?kM APPLICANT or the LOCAL.AGENCY UNDERGROUND TANK _ <br /> INSPECTOR <br /> 3. please type or print clearly all requested information. <br /> '_F _._ 4. Use a hard point writing instrument,you are makmg'3'c6pics. <br /> TOPPOFI Itom-MARK ONLY ONE rmw <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 DESCRIPTION-COMPLETE ETE ALT,ITEMS-IF UNKNOWN-, SPBC[ , <br /> A. Indicate owners tank11) #-If there is a tank number that is used by the owner to identify:the.fails (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 /> B. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE 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 /> UL 'TANK CONSTRUCTION-MARK ONE rTEM 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 OTIIL'R,print in the space provided. - <br /> IV. PIPING INFORMATION <br /> L 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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION , <br /> 1. Indicate the LEAK DEI'ECDON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INI'ORMATION ON TANK FF.RMANFNIIN CLOSED IN PLACE <br /> 1. ESTIMATED DAIS LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTINIATED QUANTTTY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> -3. WAS TANK FILLED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR TME 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 /> ITIS THE RESPONSIBILITY OF THE LOCM,AGENCY THAT IN.%TECrS'I71E FACILITY TD VERIFY THE <br /> ACCURACY OF T1 IE INItORMATION. 711E LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE <br /> "LOCAL AGENCY USE ONLY'INFORMATION BOX AND ICOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM'B'(s)TO TIIE FOLLOWING ADDRESS. <br /> STNFE OF CALIFORNIA <br /> SLATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.EEPS. <br /> DATA PROCESSING CFE ER <br /> P.O. BOX 527 <br /> PARAMOUNT,CA WM <br />