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INSTRUCIlONS FOR COMPLETING FORM'B' <br /> GENERAL INSTRUCTIONS: <br /> L One F012M "B" shall be completed for each tank for all NFW PF,RMI7S,PERMrr CTIANGFS, RIIMOVAI S and/or anv <br /> other TANK INIIORMAT70N CHANGE <br /> 2. This form should be completed by either the PERMIT'APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECEOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'FOP OF FORM: 'MARK ONLY ONI?rFEM' <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 D13A or Facility name where the tank is installed. <br /> 1. 'TANK DESCRIPTION-COILfPI.=ALL rIP,MS-Br 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. 2$,000 or 10,000 etc.). <br /> 11. 'TANK CON773NV% <br /> A. 1. If MOTOR VEIIICLP. FUEL,check box 1 and complete items B & C. <br /> 2. If not MOTOR VEHICLE FULL, check the appropriate box in section A and complete items B R D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FULL(if box 1 is checked in A). <br /> D. Print the chemical name of the ha%ardOUS substance stored in the tank and the C.A.S.#. (Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE MM ONLY IN BOX A, K C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING.and CORROSION PROTF..(TION. <br /> 2. If O'rimik,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 LEAK DMT.0 ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEILC770N <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PL'RMANEN11.Y CLOSED IN PLACE <br /> L ESTIMATED DATE[AST USED - MONTI-I/YEAR (January, 1988 or 01/88). <br /> 2. ESI7MATFD QUANTITY or IIA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WrilI INERT MA'ITRLA L? Check 'Yes'or WO'. <br /> APPLICANT MUST SIGN AND DAl7;711E PORN AS INDicwrED. <br /> INSTRUCTION POR TIIE 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 tic the same as shown in form "A". The <br /> tank number may he assigned by the local agency; however, this number must be nunwricat and cannot contain an alphabCt. If <br /> the local agency prefers the State Board to assign the tank number,please leave it blank. <br /> IT IS THE RESPONSIBB.I7Y OP'I11E]LOCAL AGENCY'IIIAT INSPIiFc S 711E FAC7I.ITY TO VFRII'Y 77R? <br /> ACCURACY OPME INFORMATION. TYPE LOCAL.AGENCY IS RISPONSIRLE FOR"TILE COMPLETION OF'I7B:i <br /> 'LOCAL AGENCY USE ONLY' INFORMATION BOX AND POR FORWARDING ONE FORM'A'AND AS,SOCIAII?D <br /> FORM '11'(s)TO 771E FOLLOWING ADDRESS. <br /> SIAM OF CALIFORNIA <br /> ST'A'IR WATER RESOURCES CONTROL BOARD <br /> C/O&W.EEP.S. <br /> DATA PROCESSING CTrN TFR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br /> 0 `' <br />