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INSIRUCIIONS FOR COMPLLqWG FORM"B" <br /> GENERAL INS RUCTIONS:- <br /> T. One FORM"B'shall be completed for each tank for all NEW PERMITS,PERMIT CIV\NGES, RFMOVAI.S and/or any <br /> otherTANK INFORMNITON CHANGE. <br /> 2. This form should be completed by either the PFRmrr APPI1CANFor the LOCAL AGENCY UNDERGROUND TANK. <br /> INSPFCIX)R. <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 ow ramw <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 I)BA or Facility name where the tank is installed. <br /> 1. TANK DFSCRIMON-COMPLU1713,ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 111) # - If there is a tank number that is used by the owner to identify the tank(cx.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK M11G.). <br /> C. Indicate the year the tank was installed(ex. 1.987). <br /> D. Indicate the tank capacity in gallons(ex. 2.5,0(X)or 10,000 etc.). <br /> 11. TANK CONI`I?NFS <br /> A. 1. If MOTOR VEHICLE FUI:11,check box 1.and complete items B &C. <br /> 2. If not MOTOR VFIIICLE FULL,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 1 is NOT checked in A. <br /> 111. TANK CONST'RUCIION-MARK ONE raim ONLY IN BOX.A,B,C&D <br /> L Check only one item in TYPE Of,SYSTEM,TANK MATERIAL, INT1111-UOR LINING and CORROSION PROTE `rION. <br /> 2. if O'I'LIER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 1 If UNKNOWN, circle; or if OTIIEF.,print in space provided. <br /> 3. Indicate the LEAK I)I.,,TFCI1ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUIWI ION <br /> 1. Indicate the LEAK DI'll-ITICIJON syrstern(s) used to comply with the monitoring requirements for the tank. <br /> VI. Mq)RMAIION ON TANK PERMANFN11,Y CLOSED IN PLACE <br /> 1. ES11MATED DATE I.AsT Usti) - MON`I'I1/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of TIA7ARI)OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK F11114,D WH It INERTMATT:,RIAL? Check 'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DAIE'ITIP FORM AS INDICA 'ED. <br /> INSTRUCTION FOR,nw wcAL Acum"ms <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 /> rr IS 17-11!RESPONSIBI1117Y Of'TITE IA-)CAI,AGENCY TIIATINSPIX'I'S 11IF FACIL171Y TO VFRIVY'111E <br /> ACCURACY OF 111E INFORMN110N. TITE LOCAL AGENCY IS RESPONSIBLE FORTIIE COMI'll 1-11ON OF TIIE <br /> 'LOCAL AGENCY USE ONLY'INFORMN11ON BOX AND FOR FORWARDING ONE FORM"A!AND ASSOMFED <br /> FORM FOLLOWING ADDRESS. <br /> S'VVIV 017 CALIFORNIA <br /> STA111 WA113R RESOURCES CONTROL BOARD <br /> C/o S.W.RLP.S. <br /> DATA PROCESSING CIWIT--R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 901723 <br />