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INS17RUCIIONS FOR COMPIHITNG FORM*B" <br /> GI NURAL INS`1`RUCTIONS- <br /> 1. One FORM"B"shall be completed for each tank for all NEW PE.RM1717S,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGIL <br /> 2. This form should be completed by either 1hc PERMrr.APPLICAN['or the lf",AL AGENCY UNDERGROUND TANK <br /> INSPEC1.70R. <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 MW* <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 isinstal!edi. <br /> 1. TANK DF-SCRH7ION-COMPLUIT-4 ALI.ITEMS-U41 UNKNOWN-SO SF 1XIFY <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.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 /> If. TANK CONTENTS <br /> A. 1. If MOTOR VEHICLE; 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 VEHIC1.11 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.#. (Chermcal Abstract Service <br /> number), if box I is NOT checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM;'TANK MATERIAL,INFERIOR LINING and CORROSION PROTECTION. <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 DFI'EcnON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLTrF(31ON <br /> 1. Indicate the LEAK D17ni.cTiON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ONTANK PERMANINII.Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR (January, 1988 or 01/88). <br /> 2. ESI'IMATED QUAIVITIN of HAZARDOUS SU135FANCE' remaining in the tank(in Gallons), <br /> 3. WAS TANK FILLED WITH INERT Check 'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND I)XILI TIIE FORM AS INDICNITI.D. <br /> INSTRUCTION FOR THE.LOCAL AGENCIF-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)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+c Board to assign the tank number,please leave it blank, <br /> IT is 17113 RESPONSIBILITY OF 71111 LOCAL AGENCY ITINFINSPI"'S71111,FACII11"Y TO VERITY"111E, <br /> ACCTJRACY OFTIW,INITORMA110N. THE LOCAL AGENCY IS RESPONSIBI,E FOR 111E COMPI1rI1ON OF 1111? <br /> *LOCAL AOFANCY USE ONLY*INFORMNITON BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCINI-111) <br /> FORM'Ir(s)TO 711113 FOI1.OWING ADDRESS. <br /> STA7111.1 OF CALIFORNIA <br /> 91XI11 WATER RESOURCES CONTROL BOARD <br /> C/o S.Wn T�T-P.S. <br /> DATA PROCEWNG CI:WI17R <br /> P.O.BOX 527 <br /> PARAMOUNT,C.A.9072'3 <br />