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IN91RUCIIONS FOR COMPLETING IK*Fr • <br /> GENERAL INSTRUCTIONS <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any <br /> other THINK INFORMATION CHANGE. <br /> 2. 'Phis form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> <a <br /> INSPECTOR <br /> 3. Please type or print clearly all requested information. <br /> - --- 4. Use a hard point writing instrument,you an making 3 copies. <br /> ',IP )``� FORM: 'MARK ONLY ONE ITEM' <br /> 1. Mark an (X)in the box next to the item that best jdescribes'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 ALL IIT?MS-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 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 CONTENIN <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 VE14ICLE FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in The-taak.araWhe CA.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. _ <br /> TB. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,II,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 OTHER,print in space provided. <br /> 3. Indicate the IIiAK DETECTION 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- INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of FLAZARDOUS SUBSTANCE remaining in the,tank(in Gallons). <br /> 3. WAS TANK TILLED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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 THE RFSPONSIBBSTY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY TILE.. <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLU,TION OF THE <br /> 9ACAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A•AND ASSOCIATED <br /> FORM'B'(s)TO 171EVOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.ESS. <br /> DATA PROCESSING C@ILER <br /> P.O-BOX 527 <br /> PARAMOUNT,CA 90723 <br />