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INSTRUCTIONS FOR COMPLETING FORM 4T" GENERAL INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PE'RMI'T'CHANGES, REMOVALS and/or any other TANK INFORMATION CHANGE 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPEC>;O 3. Please type of Rrint clearly all requested information. 4. Use a hard point writing instrument,you am making 3 copies. TOP OF FORM:"MARK ONLY ONE rTEM• 1. Mark an (X)W tpc,pox pyxt to the item that best describes the reason the form is being_cgnlPleled. ' 2. Indicate the Dt3A'orT°aeil ty'name where the tank is installed. - L 'TANK DESCRIPTION-COMPLETE ALL rTEMS-IF UNKNOWN-SO SPECIFY . A. indicate owttets 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- (cx.ACME TANK MPG.). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons (ex.25,000 or 10,000 etc.). B. TANK CONTENTS - A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. 2. If not MOTOR VEHICLE FUEL,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 C.A.S.#. (Chemical Abstract'sluvice number),if box 1 is NOT checked in A. BI. 'TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D 1. Check only one item in TYPE OF SYSTEM,TAN*MATERIAL, INTERIOR LINING and CORROSION PROTECTION. 2. If OTHER,print in the space provided. ` 1V. PIPING INFORMATION .- 1. Circle A if above ground;circle U if underground;and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DEMCISON system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DETECTION 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANENTLY CIASE.D IN PLACE 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). 2, ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH]NERC MATERIAL? Check'Yes'or'No'. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES 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 111E dX 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 TTIE RESPONSIBILITY OF THE LOCAL AGENCY TINT INSPECTSTHE FACILITY TO VI TAW T1H? ACCURACY OF TI IE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIM 'IACAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORMA'AND ASSCX7ATT3D FORM•B"(s)TO TIIE FOLLOWING ADDRESS. STATE OF CALIFORNIA '\i �- t:•,r,I,. STATE WATER RESOURCES CONIROT,BOARD C/O S.WX-E.P.S DATA PROCESSING CENTER _ P.O.BOX 527 PARAMOUNT,CA 90723 r