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VT 7 77, 77-r <br /> INSTRUGIIONS FOR COMPMUTNG, FORM-B- <br /> GFNFRAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PF.RMrIN PERMIT CIIANGPES, REMOVALS and/or anv <br /> other TANK INFORMA11ON CHANGIL <br /> 2. This form.should be completed by either tlic, Pi!,.Rmrr APPLICIANWor the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECI7OR. <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 1'1104* <br /> 1. Mark an (X)in the box next to the item that best describe,,, the reason the form is being completed. <br /> 2. Indicate the DBA or Iacility name where;the tank is <br /> I. TANK DVSCRIP17ON-COMPIZIE ALL 1`112AS-IF UNKNOWN-50 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 (C-<,ACMF.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,W0 etc.). <br /> 11. TANK CONFENI'S <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. <br /> 2. If not MOTOR VEI-IILE 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 VEIHICLE 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 I is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE MiM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYS`IEM- ,TANK MATERIAL,INTERIOR LINING and CORROSION PROIU�CrJON. <br /> 2. If OTHER,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 OTfIER,print in space provided. <br /> 3. Indicate the LEAK DE`n3criON system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DLFrF(71ION <br /> 1. Indicate the I.J,:AK Df1IT'CTiON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMK11ON ON TANK PERMANENTLY CII)SED IN PLACE <br /> 1. ESTIMAJ111) DATE LASTUSED-MONTI I/Yl."!d*\R (January. 1988 or 01/88). <br /> 2. ESTIMATED QuANITry of IIA7ARDOUS SUBSl'ANCl3 remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wini INER'I'MA'FERIAL? Check 'Yes' or'NO'. <br /> APPLK ANT MUST SIGN AND DMILVIIIE -MRM AS INDI(W1111 <br /> IN.S`1RUC17ON MR 11113,IA)CAL 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 nun&r 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 /> rI'ISTII1.?RESPONSIBILITY OF 11111 LOCAL AGENCY TlVVFINSPIXJN 11111 FACILI71'Y TO VERIFY'111E <br /> ACCURACY 011111F,INFORMATION. TIII!LOCAL AGENCY IS RESPONSIBLE FOR'IIEB COMP11717ON OF ITIE <br /> "LOCAL,AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCINI10 <br /> FORM "B"(s)TO-11111 FOLLOWING ADDRESS. <br /> SrX113 OF CAIIFORNTA <br /> STAID WNI'ER RFSOURCt3S CONI'ROL BOARD <br /> C/o S.W.1EP.S. <br /> DATA PROCESSING CEN1171k <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9(rM <br />