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INSTRUCTIONS FOR COMPIHIING FORM*B" <br /> GENERAL INS'TRUCT'IONS: <br /> L One FORM"B"shall be completed for each tank for all NEW PFRMr.VS,PFRMrl7 CHANGES, REMOVAUS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPI.JCANI'or the LOCAL AGENCY UNDERGROUND'I'ANK <br /> INSPE(7110R. <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 nim <br /> I. 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 DESCRIVITON-COMPIHM4 ALL 111WS-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. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. TANK CA)NIMNIN' <br /> A. 1. If MOTOR VEHIC1,11 FUEL,check box I and complete items B &C. <br /> 2. If not MOTOR VEI-IICIA1 FUEL,check the appropriate box in section A and complete items 8 & D. <br /> 13, Check the appropriate box. <br /> C. Check the type of MOTOR VEIIICLE 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 /> 111. TANK CONSMUC17110N-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION I`RoTE�CnON. <br /> 2. If OTHER, print in the space provided. <br /> IV. PIPING INFORMATION <br /> L Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTIIER,print in space provided. <br /> 3. Indicate the LEAK DP-,I'I'-,CrION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETEC11ON <br /> 1. Indicate the LEAK DE`I`EC11ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA31ON ON TANK PERMANEN17.Y CIA)SED IN PLACE <br /> 1. ESTIMATED DAI I E LASI-USED-MONTII/YEAR(January, 1.988 or 01/88). <br /> 2, ESTIMATED QUANrl'rl'Y of HAVARDOUS SUB,5IANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wini INERT MA1'ERIAL? Check 'Yes'or'NO'. <br /> APPIICANT MUST'SIGN AND DNIN 11-111 FORM AS INDICWfED. <br /> IN,13TRUC11ON IZORTIHI LOCAL AGENCM7-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 State Board to assign the tank number,please leave it blank. <br /> TI'IS11-113 RESPONSIBHXff OF IIIE I)OCAL AGENCY nINFINSPECINTME FACIIXIT'110 VI RIFIf 711E <br /> ACCURACY OIVIIIE INI?ORM/V.IION. Mill LOCAL AGENCY IS RESPONSIBLE FOR'171131 COMPIZI]ON OF ITIE <br /> 'LOCAL AGENCY USE ONLY*INFORMNIION BOX AND FOR FORWARDING ONE FORM*Am AND ASS0CtA'IV-D <br /> FORM-Br(s)TO 1711111 FOLLOWING ADDRESS. <br /> STA'113 OF CALIFORNIA <br /> SrNIE WATER R11SOURCUS OON17ROL BOARD <br /> C/O S.W.114 E.P.S. <br /> DATA PROCIISSING CENTER <br /> P.O.BOX 577 <br /> PARAMOUNT,CA 90723 <br />