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INSTRUC'T'IONS FOR COMPIH17I 1G FORM'B' <br /> GENERAL INSTRUCTIONS: <br /> L One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, RI,MOVALS and/or any <br /> other TANK INFORMA'I1ON CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC'T'OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> OF FORM: "MARK ONLY ONE M.W* <br /> L 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 DE:SC:RIP71ON-COMPLETE ALL T1`EMS-IIr UNKNOWN-SO SPEC <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 VEHICL:Ei FUEL.,check box 1 and complete items B&C. <br /> 2. If not MOTOR VELIICLEZ FUEL..,check the appropriate box in section A and complete items B& D. <br /> Ii. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICL 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 /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C di:D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INI'ERIOR LINING and CORROSION PROTI:-.c1ON. <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 OT"ITER,print in space provided. <br /> 3. Indicate the LEAK 13ETI'3CTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DE'TV(11ON <br /> 1. Indicate the LEAK 131711 CTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INI-'ORMATION ON TANK PERMANINI7 Y CIA).SED IN PLACE <br /> L ESI'IMAIED DATE LAST USED-MONTI3/YEAR(January, 1988 or 01/88). <br /> 2. ESI'IMATED QUA?VITI'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL.? Check'Yes'or'NO'. <br /> APPLICANT'MUST SIGN AND DATE TI-IE FORM AS INDICATED. <br /> INS-IRUCIION FOR T'ITE LOCAL AGENCLES <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 I3oard to assign the tank number,please leave it blank. <br /> rI'IS 11II1 RESPONSIBILITY OF 114E IACAL AGENCY THAT INSPECTS T1IE FAC.IIII Y T'O VERIFY111E <br /> ACCURACY OF TIIE INFORMA7110N. 17111 LOCAL.AGENCY IS RESPONSIBLE FOR T1IE COMPLETION OF T1IE <br /> 'LOCAL AGENCY USE ONLY"INPORMAIION BOX AND FOR FORWARDING ONE FORM"A"AND AS.SOCIAIED <br /> FORM"B"(s)TO 1,1111 FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAI1:WATER RESOURC[rS CONTROL BOARD <br /> C/O&W.E-F-P.S. <br /> DATA PROCESSING (MI11ER <br /> P.O.BOX 527 <br /> PARAMOUNT,C'A 90723 <br />