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INSTRUCTIONS FOR COMPIHIING FORM*B' <br /> 61-MIRAL INS�IRUCTIONS- <br /> t One FORM'B"shall be completed for each tank for all NEW PERMIT`S,PERMIT CHANGIN, REMOVAUS and/or any <br /> otherTANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANI'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC170R. <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. <br /> 1. TANK DF-SCRIVITON-COMPIH1E ALI,r1`EMS-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.A1370789), <br /> B. Indicate the name of the company that manufactured the tank(ex.ACMETANK 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 CONI� <br /> A. 1. If MOTOR VEHICLI,'.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 I 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 I is NOT checked in A. <br /> 111. TANK CON,'1;'.MUCTION-MARK ONE ITUM ONLY IN BOX A,B,C&D <br /> I. Check only one item in TYPE OF SYS`TEM,TANK MAT13RIAL, INMERIOR LINING and CORROSION PROTE,'(7110N. <br /> 2. If OTHER, print in the space provided. <br /> IV, PIPING INFORMAInON <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN, circle;or if O'IIIEI;�print in space provided. <br /> 3, Indicate the LEAK DF51'EcTiON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHFFEC`1'ION <br /> L Indicate the LEAK DHIMCTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ONTANK PERMANEMI'LY CIA)SED IN PLACE <br /> 1. ESTIMA71T.13 DATE LAST USED-MONTII/YIR(January, 19M or 01/88). <br /> 1 ESHMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH LNERT MATIqRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUS-17 SIGN AND DATE TIIH FORM AS INDICKIED. <br /> INSTRUCHON FOR THE LOCAL AGL-N('_1F_S <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)731)-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 /> rl'IS717HE RESPONSIBHXI'Y 01111111 LOCALAGENCY 711ATINSPIX71S711113 FACILITY'170 VERWY111E <br /> ACCURACY OF11113 INFORMAIION. 1711[t LOCAL AGENCY IS RESPONSIBIE FOR TIIE,COMPIHIION OF TIIE <br /> "LOCAL AGENCY USE ONLY*INFORMA:I10N BOX AND FOR FORWARDING ONE FORM W AND ASSOCINIV-D <br /> MRM 'Ir(s)TO-flit!FOLLOWING ADDRENS. <br /> STA31i OF CALIFORNIA <br /> STIVIE WATER RESOURCES CONI'ROL BOARD <br /> C/O&W.111 E.P.S. <br /> DATA PROCESSING CMNrElk <br /> P.O.PDX 527 <br /> PARAMOUNI7,CA WM <br />