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INSTRUCTIONS FOR COMPIENG L A WBW_ <br /> GENERAL INSIRUCTION:i: <br /> 1. One FORM"B"shall be completed for each tank for all NEW P . S,PERMIT CHANG M. REMOVALS and/or any <br /> otherTANK INFORMN11ON CHANGE. <br /> 2. This form should be completed by either the PERMIT APPUC'ANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECIY)R <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'I'OP OF FORM:WMARK ONLY ONE I W <br /> 1. Mark an (X)in the box next to the item thai 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- MPI VW,ALL TITP1+IS-IF UNKNOWN-SO SPLG <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,25,000 or 10,000 etc.). <br /> LL TANK CONTEMIN <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 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 CONS'17RUMON-MARK ONE PTEM ONI Y IN BOX A, II,C&D <br /> 1. Check only one item in TYPE,OI'SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <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 /> 3 If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DE`IT'.CTION systems) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DM,7ECTION <br /> 1. Indicate the LEAK DITI E,CI'ION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTEI/YEAR(January, 1988 or 01/W)';� <br /> 2. ESTIMATED QUANTII.'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> .3. WAS TANK FILLED WITH INERT MA'T'ERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATI?TETT?FORM AS INDIC:,ATED. <br /> INSTRUCTION FOR"TIIE LOCAL AGENC1FS <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 /> rT IS THE;RESPONSIBIITI'Y OF THE:LOCAL AGENCY TIIAT INSPECTS THE FACILITY TO VERILY TITS <br /> ACCURACY OF THE INFORMATION. 'THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMP1 : ON 01711111 <br /> 'LOCAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM WAW AND ASSOCIATED <br /> FORM'B'(s)-1'0-I°IIE FOI..LOWING ADDRFSS. <br /> STAIE OF CAI.1FORN1A. <br /> STATE WA1ER RF-SOURC31S COWROL BOARD <br /> C/O S.WX-F P.S. <br /> BATA PROCESSING CENTI?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> f & _, <br />