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INSTRUCTIONS FOR COMPIZIING FORM'B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGPS, REMOVALS and/or any <br /> other TANK INFORMATION C2IANGE. <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-q hardfaiot�writ}ngjn56�ttment,you ale making 3 copies. <br /> 7OP OF FORM:"MARK ONLY ONE r11' C <br /> 1. Mark an(?C)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 DEscRIP170N-C6MPI..ET1?ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there 4 a tank number that is used by the owner to identify the tank(ex.A1370789). <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 /> IL TANK CONTWIN <br /> A. 1.If MOTOR VF..IIICLE 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 MO'I'OR 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 /> ITL TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,11,C&13 <br /> s <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 /> FV. PIPING INFOR><MIATION <br /> 1. Circle A if above ground;circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIF.,R,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 DETECTION <br /> 1. Indicate the LEAK DLA TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY Y CLOSED IN PLACE <br /> 1. ESTIMATED HATE LAST USED-MOVM/YFAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of 11-AZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTTII INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICAFED. <br /> IIJSI'RUCTTC ON 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 TIIE RF..SPONSIBum OF THE LOCAL AGENCY THAT INSPECI;S'KITE mcaYI Y TO VERIFY THE; <br /> ACCURACY OF 71EE INFORMATION. THE LOCAL AGFNC Y IS RESPONSIBLE FOR'THE COMPLETION OF TFIE <br /> LOCAL AGENCY USE ONLY-INFORMATION SOX t,ND FOR FORWARDING ONE,FO "A"AND ASSOCIATED <br /> FORM"B"(s)TO TIME FOLLOWING ADDRESS. <br /> STATE'OFCALIFORNIA �rVol ; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O&W.I?I?P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />