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. . <br /> INSTRUCTIONS FOR COMPLL?TLNG FORM'B" <br /> GENERAL INSTRUCIIONS: <br /> i. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT C IIANG S, REMOVAI S and/or any <br /> other TANK INFORMA7TON CHANGE. <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 I11W <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 /> L TANK DESCRIPTION-COMPI UMT ALL ITEMS-IF UNKNOWN-SO SPBC[FY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.AI370789). <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 /> II. TANK C ONT1:3NTS <br /> A. 1. If MOTOR VEHICLE;FUEL,check box 1 and complete items B&C. <br /> 2. If not MO'T'OR 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 VEHICI.,I FURL(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 ITEM ONLY IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF 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 /> 2. If UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DI'ITiC11ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLrTF.CTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CIASI3}IN PLACE <br /> 1. ESTIMATED DATE LAST'USED-MONI'HJYEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUA", TY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FIL,L,ED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DAIV'I1IE 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 arc 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 TME RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS 111E FACILITY TO VERIFY TIIE <br /> ACCURACY OF TIIE INFORMATION. 71IE LOCAL AGENCY IS RESTONSIBLI?FOR'11IE COMPLITnON OF THE <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM A"AND ASSOOK11113 <br /> FORM"LI"(s)TO TME FOLLOWING ADDRESS. <br /> STATE OF CAI.1P6RNIA <br /> STATE WATER RE.SOURC ES CONTROL BOARD <br /> C/O S.W.E.F.,.PS. <br /> DATA PROCESSING CUT NTIER <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 t <br />