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{ <br /> INSTRUCTIONS FOR COMPLETING FORM"B" <br /> GFNE'RAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS, PF_RMrr CHANGES, REMOVALS and/or any <br /> other TAMC INFORMATION CHANGE <br /> 1 'I:'his form should be completed by either the PERMIT APPLICANT'or the LOCAL AGINCY 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 1T1w" <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 DPSC:RIPTION-C!OMP11!11,-ALL 1717?MS-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..,TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 198'n. <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> II. TANK C)N"1'ENTS <br /> A. 1. If MOTOR VEHICL F7 FUEL..,check box 1 and complete items I3&C. <br /> 2.if not MOTOR VEL.IICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> 13. 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 CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INL'ERIOR LINING and CORROSION PROII3CTION. <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 /> 2. If UNKNOWN,circle; or if OTTIER,print in space provided. <br /> 3. Indicate the LEAK DF 'ECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLTrF.CI1ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA711ON ON TANK PERMANENI7 Y(3,OSED IN PLACE <br /> 1. ESTIMATED DATE,LAST USED-MONTII/Y1:AR(January, 1(A8 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSI'ANC:E remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MAT17RIAL? Check'Yes'or'NO'. <br /> APPLIC AW MUST SIGN AND DAT1?1711?FORM AS INDICKI7?D. <br /> INSf RUCI7ON FOR 111E IAX:AL 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 /> H'IS 111E RESPONS1BI111.'X OF 111I:1 LOCAI.AGENCY 11INF INSPIrl'S 173E FACILITY TO VERIFY'1111:; <br /> AC('URACY OF 111E INFORMA11ON. TILE LOCAI,AGENCY IS RESPONSIBLE FOR 1.1IE COMPLE'17ON OF T IIE <br /> 'LOCAL AGENCY USE ONLY"INFORMAIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIN110 <br /> FORM"B"(s)TO'L1'1E FOL]LOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STA'1L WATER RESOURCES C'ON FROL BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROC31SSFNG CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> w� <br />