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INSIRUCIIONS FOR COMPLI,tI7NG FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B" shall be completed for each tank for all NEW PURMl'I-S, PERM1'I'CIiANGES, REMOVAI.S and/car any <br /> other TANK INFORMA PION CHANGE <br /> 2. 'Phis form should be completed by either "he PI R-Mrr APPl IC.AIMI'or the LOCAL AGENCY UNDERGROUND TANK <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 1`170 * <br /> 1. Mark an (X)in the box next to the item that best describes the reason the form isbeing completed. <br /> 2. Indicate the DBA or facility name where the tank is installed. <br /> 1. 'TANK DESCRIPTION-COMPLE"I13 ALI.TIT?MS-IF UNKNOWN-SO SPECIFT <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 10000 etc,) <br /> 11. "TANK CON113NI'S <br /> A. 1. If MOTOR'VEIIICI..E FUEL,check box 1 and complete items B & C. <br /> 2. If not MO'T'OR VEHICLE,FUEL,check the appropriate box in section A and complete items B d D) <br /> B. Check the appropriate box. <br /> C',. Check the type of MOTOR VEI IICLE 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,#. ((:hemrcal Abstrac( Service <br /> number), if box I is NOT checked in A. <br /> 111. TANK C'ONSTRUCIION-MARK ONE MIM ONLY IDQX)X A,13,C&D <br /> I. Check only one item in TYPE OF SYS173M,"TANK MAT.I RIAL, INTERIOR LINING and CORROSION PRO'113CTLON. <br /> 2. If OTIIER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DF I'ECr1ON system(s)used to comply)with the monitoring requirement for the piping. <br /> V. TANK LEAK DLTI7..(:11ON <br /> 1. Indicate the IA AK DE1I CTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMAIION ON TANK PERMAMNILY C IA)SED IN PLACE <br /> 1. ESTIMA'11:i1) DATE IAST USED-MONTH/YTIAR(.January, 1988 or 01/88). <br /> 2. ES11MA'111.)QUAN7.TI'Y of HAZARDOUS SUBSTANCIa remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLET) WI'TIL INERT'MATERIAL.,? Check 'Yes'or'NO'. <br /> APPLICANT MUbT SIGN AND DAT1?I1I1?1,Y)RM AS INDHWIVD. <br /> IN.STRUC17ON FOR 11 IR Id)C1AL AGENCIRS <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 Sta*e Board to alsign the tank number, please leave it blank. <br /> rI'1S'11IE RESPONSIBII.ffY 0111711!I AC.AL AGl?.NC Y'1'[1AI'INSPIXTS"II IF FACILTCY'PO VERI['Y'111I? <br /> ACCURACY OF'I1W,INFORM/010N. 1111?LOCAL AGENCY IS RFSPONSIBI.,E FOR71117:C:OMP11n1ON OF 111E <br /> "IX)C1AL AGF,NC'Y USE ONLY"INFORMAIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCAIED <br /> FORM"1i"(9)TO 311B FOI.I OWING.ADDRESS. <br /> STA111 OF CAIIFORNIA <br /> STAIL WAILR RESOURCES CONI'ROL BOARD <br /> C/O&W.E.E.P.S. <br /> DATA PROCESSING CENI'ER <br /> P.O.BOX 527 <br /> PARAMOUNL',CA 90M <br /> a <br />