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INSTRUCTIONS FOR COMPIEUING•FORM-B • <br /> - <br /> GENERAL INSTRUCTIONS: <br /> L One FORM'B'shall be completed for each tank for all NI?W PERMITS,PERmrr 01LANGES, REMOVAI-S and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMr1`APP11CANf or the LOCAL AGE.-NCY UNDERGROUND TANK <br /> INSPECTOR <br /> 1 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 11134'- <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 I'acility name where the tank is installed. <br /> T. TANK DESCRIPTION-COMPIM]Mi All.1171EMS-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 TANV MI"G.), <br /> C. Indicate the year the tank was installed (ex, 1987). <br /> 1). Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br /> 11. TANK CONJI-NIN <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 tyles of MOTOR VEHICLE FUEL(if box 1 is checked in A). <br /> 1). 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 /> W. JANK(,ONS-1RUC11ON-MARK ONE rIEM ONLY IN BOX A,13,C&1) <br /> L Check only one item in TYPE OL'SYSrEM,TANK MATERIAL,,INTERIOR LINING and CORROSION PROTLsCTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> I Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 1 If UNKNOWN,circle; or if OTHER, print in space provided. <br /> 1 Indicate the LEAK DETECHON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK I.MK DVIEf.711ON <br /> 1. . Indicate the 11-,, DE TFCH0N systc, <br /> (a)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ONTANK PERMANEmmy a)OSFD IN PI ACF <br /> 1. K511MA'I'l,"D DATE LAS['USED - MOiNTfll/YrAR(January, 1988 or 01(88). <br /> 2. T=S`IMATED QUAN'TITY of HA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WFII I INERT MATERIAL? Check'Yes' or 'NO'. <br /> APP11CANIr MUST SIGN AND DA`111 1111i K)RM AS LNDICATI.D. <br /> INS-I.`RU(7t1ON FOR 11 IE LOCAL AGENCH N <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)739-242L The facility number must be the same as shown in form "A". The <br /> tank number maybeassigned by the locaf 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 /> VF IS'174E RFSPONSIBHXI'Y OF'IlIE LOCAL AGENCY THAT'INSPE(NSTILE FACILITY TO VERIFY 11111 <br /> ACCURACY oFTILE INFORMATION. <br /> ITAWAL AGENCY USE ONLY"INFORMATION BOX AND POR FORWARDING ONE FORM*A7 AND ASSOCIATED <br /> FORM-Ir(s)110 11111 FOI.l OWING ADDRESS, <br /> STAII OF CAIJFORNlA <br /> invi �WATER RI SOURCES CONIROL 130ARD , <br /> C/O&W.E-F-P.S. <br /> DATA PROCI-ISSING CENIER <br /> P.O.BOX 527 <br /> PARAMOUN'r,CA 90723 <br />