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-7. 1W <br /> 3 <br /> IN1,;1'RUC1[1ONS FOR COMPI.LqING FO,RM'B' <br /> GENERAL INS717RUCIIONS- <br /> L One FORM"B"shall be completed for each tank for all NEW PERM11N, PERM171'(31ANGES, RIWOVAI-S and/or any <br /> other TANK INFORMA'nON CFIANGF- <br /> 2. This form should be completed by either the PERMIT APPLICANFor the LO(IM,AGENCY UNDERGROUNDTANK <br /> INSPECIDR. <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 PORM: -";o`Niy, oNu rmAr <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 tVe D13/,k or Facility name where the tank is installed. <br /> L TANK DaSCRIP'11ON C)MP1,13111 ALL rITMS-fil UINXINOWN-SO SPECH-1Y <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.ACMETANK 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 /> H. TANK CONIIINIS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items 11 & C. <br /> 2.If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B & D. <br /> & Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL(if box I 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 /> 111. TANK CONSI'RU(7I7ON-MARK ONE IITAI ONLY IN BOX A,11,C&D <br /> 1. Check only one item in TYPE OI7, SYSTEM,'TANK MATERIAL, M17ERIOR LINING and CORROSION PROTEK71ION. <br /> 1 If OTI-IER,print in the space provided. <br /> IV. PIPING INFORMNNON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 1 If UNKNOWN, circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DETECrION systern(g) used to comply with the monitoring requirement for the piping. <br /> V. TANK LMK D11111CITON <br /> 1. Indicate the LEAK DFITECTFION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMXIION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. F-S-FIMA'I'l3l) DATE.LAST USED - MONTII/YI>tkR(January, 1988 or 01/88). <br /> 2. EgnmATEM QUAN1111-Y of HAZARDOUS SUI35FANCE remaining in the tank(in 6aflons). <br /> 3. WAS TANK FILLFID WITH INEWpNixrF'RIAL? Check'Yes'or <br /> APPLICANI'MUS-F SIGN AND DA71V 111E FORM AS INDICNIT3). <br /> IN9117RU(7110N FOR TI IL LOCAL,AGENCII-TS <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)719-2421. 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 /> rl'IS"1'111?RFSPONSHIIIXFY OF'IIIE DOCA1,AGENCIf 111N]'INSPECTS 11111 FACILtIT TO VERIFY TIIE <br /> ACCURACY 01717m mzoRmNnom nw LOCAL AGENCY IS Rn-SPONSIBLE MR 111E COMPIE17ON OF 11113 <br /> 'LOCAL AGENCY 1USF,ONLY'INFORMATION BOX AND 14OR FORWARDING ONE FORM"A"AND A.W)CIA1111) <br /> R)RM"13"(s)TO 11111 FOLLOWING ADDRESS. <br /> 917VII3 OF CALIFORNJA <br /> I <br /> F -1-4�WAT �" 'IrCRS CONTFROI,BOARD <br /> P.O.IX)X 527 <br /> PARAMOUNI-,CA AYM <br />