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INSTRUCTIONS FOR WMP117MG "B" <br /> GENERAL IN,%RUCTIONS. <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERA TT CHANGIFA RE OVAI.S and/or any' <br /> other TANK INFORMKIION CI-IANGE. <br /> 2. This form should be completed by either the PERmrr APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <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 FOM-*MARK ONLY ONI? " <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.DESCRIPTION-COMPLE?TE ALL I TI?MS-IF UNKNOWN-,So SPECIFY <br /> 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. 25,000 or 10,000 etc.). <br /> 11. TANK CONK N`1 <br /> A. 1. If MOTOR VEHICLE FUEL,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 /> 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 CONSTRUCTION-MARK ONE ri .r ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAE„ INTERIOR LINING and CORROSION PROTECIION. <br /> 2. If OTHER,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 O'I1IER print in space provided. <br /> 3. Indicate the LEAK DE'ITC'I'ION sy-,tem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUM..0 ION <br /> 1. Indicate the I..I:AK DEI'ECI'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANFWI`1 Y CLOSED IN PLACE <br /> 1. FS'I'IMATED DA'I'S LAST USED-MONTEI/YEAR(January, 1988 or 01/88). <br /> 2. FSTIINIA`I'ED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INEWI'MATERIAL? Check'Yes'or:NO'. <br /> APPLICANT MUST SIGN AND DATE'11111,FORME AS INDICIA11:1). <br /> IN. UC%ION FOR'LIIE 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 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 /> ri'IS THE RESPONSIBIIXI Y OF THE LOCAL AGENCY THKI'INSPEC"1`%'IIIE FACILITY TO VERIFY TIIE? <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGFNC,'Y IS RE::SPONSIBLE FOR 7111E COMPLE=TION OF 1711? <br /> '1;O AL AGENCY USE ONLY"INFORMATION BOX AND FOR.FORWARDING ONE FORM"A"AND AS.SOCaAtED <br /> FORM"B"(s)'1'0 HE FOLLOWING ADDRFSS. <br /> STKIT OF CALIFORNIA <br /> STATE WK.II?R RESOURCES CONTROL BOARD <br /> C/O S.W.E.EPS. <br /> DATA PROCT' SSING CFNLER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />