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INSTRUCTIONS FOR COMPI..I?TING I 'B' <br /> GENERAI.INSTRU O <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGPS, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the I.,OCAL AGENCY UNDERGROUND TANK <br /> INSPEC 1170R <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 FORAC'MARK ONLY ONE ITEM" <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 /> I. TANK DESCRIPT[ON-COMPIJ?TE ALL PI x S-IF UNKNOWN-SO SPECIFY <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 /> H. TANK C.ONTENIS <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 VEIIICLE 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 1'I1°N ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE.OF SYSTEM,TANK MATERIAI,, 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 /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LE-AK DI IECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the 1,FAK DET'EC`TION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEMI.Y CLOSED IN PLACE <br /> 1. ES'T'IMATED DACE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. FSTIM.NITI)QUANTITY of HAZARDOUS SUBSI'A.NCE remaining in the tank (in Gallons). <br /> t�. WAS TANK FILLED wrn I INERT MATERIAL?Check 'Yes'or'NO'. <br /> APPI1C ANT MUST SIGN AND DATE l lIE FORM AS INDIC NIED. <br /> INSTRUC,IION I?OR'111E LOCAI.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(91.6)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 /> — <br /> ITIS TIII?RISPONSIBHXI'Y OF TITLE I OCAI,AGENCY THAI'INSPEC.IS TIIE FACILITY TO VERIFY TIIE <br /> ACCURACY OF TIIE INFORMATION. 'TIIE LOCAL AGFNC.'Y IS RISPONSIBI.E FOR TIIE COMPI : ON OF 7111? <br /> 'LOCAL.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM'B'(s)'TC?TIIE FOIJ.OWING ADDRESS. <br /> STATE OF CAI,IFO A <br /> S`rATE WATER ER RE.SOURC S CONTROL BOARD <br /> C/O S.W.E.E.P.,. <br /> DATA PROCESSING CENIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />