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INSI'RUCIIONS FOR COMPIJUING FORM'B' <br /> GENERAL INSTRUCTION& <br /> 1. One FORM"B"shall tie completed for each tank for all NEW PERMITS,PERMYr CIIANGE� REMOVALS and/or any <br /> other'TANK INFORMATION CHANGIt <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPF.C170R <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 FORM:"MARK ONLY ONI?MW" <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 DBA or Facility name where the tank is installed. <br /> 1. TANK DF5(:RIP'IION-COMPI.LrIM ALL[PENS-IF UNKNOWN-SO SPECIF1f <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 MF(3.). <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 /> H. 1ANK CONE1?NTS <br /> A. 1. If MOTOR VEHICLE FUI?L,,check box I 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 VEHICLE FUEL(if box 1 is checked in A). <br /> I). Print the chemical name of the hazardous substance stored in the lank and the C.A.S.#. (Chemical Abstract Service <br /> number), if box 1.is NOT checked in A. <br /> III. 'TANK CON4;L7tUC11ON-MARK ONE rIIN ONLY IN BOX A,11,C&D <br /> 1. Check only one item in'TYPE OF'SYSTEM,TANK MA11sRI.AI.,, INTERIOR LINING and CORROSION PRO`I'ECHON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMN11ON <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 DF-rECI1ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LIAK DI?'I'EiC CON <br /> 1. Indicate the LEAK DE'II3CTI0N systems)used to comply with the monitoring requirements for the tank. <br /> VI. INI�ORMAIION ON TANK PERMANFNII.Y CI..OSF.D IN PLACE <br /> 1. E.S'I'IMATBD DATE LAS"I'USED-MONTII/YEAR(January, .1988 or(01/88). <br /> 2. ESTIMATED QUAN'TTTY of IIA%ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK IILLED WTI'II INERI'MATERIAE? Check 'Yes'or'NO'. <br /> APPI.ICANr MUST'SIGN AND DNTE'1111?FORM AS INDK:A1T31 <br /> INSTRU(.'.I ON,POR 11EE:LOCAL AGPN('0% <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. 'Me 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 RESPONSII3HM OF 111E LOCAL AGENCY 1 ixr INSPECI511II3 FAC7LIT'Y'TO VE:RIPY 171E <br /> ACCURACY OF ITH, INFORMNIION. 771E LOCAL AGENCY IS RI?SPONSIBI F FOR'11LIi COMPLE711ON OF'nlf," <br /> *LOCM,AGENCY USE;ONLY"IN17ORMA1TON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC7ATI?D <br /> FORM-B'(s)'M 11IE FOLLOWING ADDRESS. <br /> ST rE OF CAIJII'ORNIA <br /> NDVF?WNIMR RESOURCES CONTROL BOARD <br /> C/O S.W.I?Ii?P.S. <br /> DATA PROM SING CFN113R <br /> P.O.13OX 521 <br /> PARAMOUNT,CA 90723 <br /> -.idt+�:ratsA�t�l�: �; `�i'�..' ak''�f',Jr it, ' +?"...�„�...�,•�5.•�t ?� -�oci `1�:,+ `.5diraSd;• a. - "•_ - <br />