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INSIRUCFIONS FOR COMP1171ING P*'fr GENERAL INSIRUCFIONS: 1, One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGFA REMOVALS and/or any other TANK INFORMA"HON CHANGE. 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TDP OF FORM: 'MARK ONLY ONE rFEM" 1. Mark an (X) in the boxnextto the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK DESCRIPTION-COMPT.EFU ALL rl'EMS-IF UNKNOWN-SO SPECTFY A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank (ex.AB70789). B. Indicate the name of the company that manufactured the tank (ex.AC:MF TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc) H. TANK CONEEN1S A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. 2. If not MOTOR VEHICLE FURL, check the appropriate box in section A and complete items B & D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service number), if box 1 is NOT checked in A. III. TANK CONSTRUCTION-MARK ONE I gd ONLY IN BOX A,R,C&D 1. Check only one item in'TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTEC`T'ION. 2. If OTHER, print in the spam provided. IV. PIPING INFORMATION ' 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. if UNKNOWN,circle; or if O'FIIER,print in space provided. 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DTTI'ECpION 1. Indicate the LF,AK DEFE(TON system(s) used to comply with the monitoring requirements for the tank. VL INIDRMATION ON TANK PERMANENI7.Y CLOSED IN PLACE 1. ESTIMATED DATE LAST USED-MONTIIJYFAR(January, 1988 or 01/88). 2. ESTIMA'T'ED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL,? Check'Yes'or'NO'. APPLICANT MUST SIGN AND DATE TUF FORM AS INDIC NITD. INSFRU(11ON FORTIIE LOCAL AGENCIFS The state underground storage tank identification number is composed of the two digit county number, the.three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in form "A'. The tank number may be assigned by the local agency, however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number. please leave it blank. IT IS THE RESPONSIBRSIY OF THE LOCAL AGENCY TIINF INSPF.CIN 11IE FACTLrIY TD VERIFY THE ACCURACY OF 311E INFORMATION. 'IEE L(H'AL AGENCY IS RESPONSIBLE FOR THIS COMPLHITON OF'111II 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND A.SSOCTAIED FORM"IP(s)TO JUE FOIdAWING ADDRESS. SDYIE OF CALIIDRMA S"IATE WATER RESOURCES CONTROL BOARD C/O S.W.LF1'S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT,CA WM