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77 <br /> 777 <br /> _ . .r < .. <br /> a <br /> INSTRUCTIONS FOR COMPI ET'ING FORM-B- <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for cac-b tank for all NEW PI3xLMr1`!S,PERMIT CIIANGI_S, REMOVALS and/or any <br /> other TANK INFORMALTON CHANGE. <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 17ORM:"MARK ONLY ONES r11W <br /> 1. Mark an (X)in the box next to tite item that best describes the reason the form is being completed. <br /> 2. Indicate the W- br Facility name where the tank is installed. <br /> 1. TANK DESC:RI'P'17QN-QUM'PI-FI17 AU.ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11) # - 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 /> II. TANK CONIIW.I'S <br /> A. L If MOTOR VEHICLE FUEL.,,check box'1 and complete items B df C. <br /> 2. If not.MOTOR VEHICLE FUEL..,check the appropriate box in section A and complete items I3 &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 /> M. TANK CONSTRUCTION RUCTION-MARK ONE ITEM ONLY IN BOX A,B,C dt D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If. OTI-IEI2,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. It UNKNOWN,circle; or if OTHER print in space provided. <br /> 3. Indicate the LEAK DEFECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK IAK DE Fr17ION <br /> 1. Indicate the LEAK DEIMICTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEIMY CLOSED IN PLACE <br /> 1. EST'IMA'TED DATE IA.SFUSED-MON`FII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of 11A7ARDOUS SUBSTANCE rema;ning in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL?Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA173111E FORM AS INDICATED. <br /> INSTRUCTION FOR TIIE LOCAL AL 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 Gate Board (916)739-2421. The facility number must be the same as shown in form "A". T'he <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 71IE RISPONS113ILTIT OF 1111:I OCAL AGENCY THAT INSPECIS T HE FAC:II.ITY TO VERIFY 1TIE <br /> ACCURACY OF TILE OUIORMAIION. THE LOCAL AGENCY IS RESPONSIBLE 1701111113 COMPLIT11ON OF T1111 <br /> *LOCAL AGENCY USE ONIY-INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOC1A'IT3D <br /> FORM-B-(s)TO'11111 FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAI1?WKIER RESOURCES CONTROL BOARD <br /> C/O S.W.E.E:P.S. <br /> DATA PROCESSING CI?WIER <br /> P.O.BOX:527 <br /> PARAMOUNT,CA 90723 <br />