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IN,%-FRU(.`11ONS FOR COMPLHIING FORM"B' <br /> GENERAL INFFRUC1'IONS- <br /> L One FOKN11 "B"shall be completed for each tank for all NEW PERIARN, PERMIT CIHNNGES, REMOVAI-S and/or any <br /> other TANK.INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPUCANI'or the LOCAL AGENCY UNDERGROUND SANK <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 /> L 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 DF-SCRIPTION-COMPLLq1?All,TITNS-III UNKNOWN-So SPI]Clfry <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 CONEWIN, <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 &1.). <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 1'RU(.*IION-MARK ONE ITER(ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in`TYPE OF SYSTEM,TANK MATERIAL,INFERIOR LINING and CORROSION PRO'T'ECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if undergroun&,and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTIIER,print in space provided, <br /> 1 Indicate the LEAK DEFECTION syqcm(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DLqVCIION <br /> L Indicate the LEAK DI.4,TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PIA(li <br /> I. ESTIMATED DATE LA5I'USED -MONTFII/YEAR (January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUIKI'ANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFFII INFIxr MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE771E FORM AS INDICATED. <br /> IN'13TRUCIION FOR THE LOCAL AGFNCIRS <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 REsPoNstBUITY 0171TIE IA')CAL AGINCYTI[IXIINS TM.7STI1E FACLtM TO VERIrY'I1IE <br /> ACCURACY OlznIE M?ORMNIION. T]IIE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPIJfiIION OF11IE <br /> "LOCAL AGENCY USE ONLY"If4FORMA71TON BOX AND 11OR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM-13-(s)71-0111137 FOLLOWING ADDRESS. <br /> STNIV 017 CALIFORNIA <br /> SrS111"WATER RIWUR(-'F-S CON17ROL 13OARD <br /> C/o smnu <br /> DATA PROCESSING CEMI-LIR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 9GM <br />