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tt , <br /> INSTRUCTIONS FORC"OMPLF..IING FORM'B' <br /> GENERAL INSTRuenoNS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PL APPLICANT or the LOCAL.AGENCY UNDERGROUND TAMC <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 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. §1 <br /> 1. 'TANK DESCRIPTION-COMPLE113 ALL ITEMS-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 TANNIC 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 CON1EMIS <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 /> M. TANK CONSTRUCTION-MARK ONE I1EM ONLY INBOX A,%C&D - <br /> L .Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTEC'T'ION. <br /> 2. If OTHER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> I. 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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEIECLION <br /> 1. Indicate the LEAK D>TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ES"IIMA"ITD DATE I.A4T'USED-MONT'II/YEAR(January, 1.988 or 01/88). <br /> 2. Ti,STIMATED QUAN1ITY of HAZARDOUS SUBSTANCE rcma;ning in the tank(in Gallons). <br /> 3. WAS TANK FILLED WII'II INERT MATERIAL?Check 'Yes'or'NO'. <br /> .APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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 /> IT IS THE RFSPONSIBIIxTY OF THE LOCAL AGENCY Timr iNSPwI:S TELE FACIIxL"lf TO VERIFY THE <br /> ACCURACY OF 7.1LE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE CAMPL r11ON OF TALI <br /> "LOCAL AG1,74CY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIAII::D <br /> FORM"B"(s)TO THE FOLIAWINC,ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.Ex& <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />