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1 1 pF <br /> INSI'RUCIIONS FOR COMPI..SITNG FORM"B" <br /> GENERAL INS'TRUC'ITONS- <br /> 1.. One DORM"B"shall be completed for each tank for all NEW PI?RMTIS,PI?RMrT CIIANGFS, REMOVALS and/or any <br /> other TANK INFORMATION C HANGF <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 FORM: "MARK ONLY ONE TTEM" <br /> 1. Mark an (X) in the bot next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or 11,16lity name where the tank is installed. <br /> I. 'TANK DESCRIPTION-COMPLI?IE ALI.,rIT?.MS-u?UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 1D # -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 /> 111. TANK CONIVIVIN <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. <br /> 2. If not MOTOR VEHICLES 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 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 /> III. TANK C ONSIRUC'1TON-MARK ONE rIr...M ONLY IN I3OX A,B,C&D <br /> 1. Check only one 'item in'TYPE OF SYSTEM,TANK MATERIAL.,,INTERIOR LINING and CORROSION PROT'EC'TION. <br /> 2. If OTI-TER,print in the space provided. <br /> IV. PIPING INFORMA71TON <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 DE1'EC'TION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEITiCnON <br /> 1. Indicate the LLAK 1313TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PF..,RMANI1N'11-Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAIvTT Y of HAZARDOUS SUBSI'ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FII.,LEI)WITH INERT MATE RL.,? Check'Yes'or'NO'. <br /> APPI.1CANT MUST SIGN AND DATI:'1111B FORM AS INDK'A1I3D. <br /> INSTRUCITON FOR'17TE LOCAL AGF.NCIE.S <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 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 TAE RESPON.SII31111Y OF 111E LO(AL.AGENCY THAT INSPF.0"LS ITIE FACILrIY TO VERIFY THIS <br /> ACCURACY 017311111 INFORMATION. THE LOCAL,AGENC.'Y IS RESPONSIBLE FOR TELE COMPLEITON OF THE <br /> "LOCAL,AGINCY USE ONLY"INFORMAITON BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM'113"(s)TO 111E FOI,LOWING ADDRI.:SS. <br /> 81:A 11?OF CAI.,LFORNIA <br /> SIA'I14,WAT][T R RI:SOURCRS CONIROI.WARD <br /> BATA P O l:S.iiNG Cl t 11-,'R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />