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a <br /> INSI'RUCIIONS FOR COMP1.JT11NG FORM'B' <br /> GENIAAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMII ,PERMIT(MANGES, REMOVAi..S and/or any <br /> other"TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECI'OR. <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 OE?FORM: "MARK ONLY ONE.I3Iw <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 is installed. <br /> I. TANK DF?S4CWP`1`FON-C OMPLU1T?AI I,7114MS-W UNKNOWN-SC)SPECIFY <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 /> H. TANK CONTENTS <br /> A. 1. If MOTOR VEIIICLEi 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 /> Ii. 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 1 is NOT checked in A. <br /> III. 'TANK CONSTRUC31ON-MARK ONE M.W ONLY IN BOX A,A,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INFERIOR LINING and CORROSION PRO'TI:X7170NN. <br /> 2. If OTIIF..R,print in the space provided. <br /> IV. PIPING INFORMATION <br /> I. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTI-IER,print in space provided. <br /> 3. Indicate the LEAK DFFECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DIFMX,'I1ON <br /> 1. Indicate the LEAK DE"I134711ON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PERMANEN11,Y CIASED IN PLACM <br /> 1. ESTIMATED DATE LAST'USED-MONTII/YEAR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANITIY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MA'ITRIAI.? Check 'Yes'or'NO'. <br /> APPucANT MUST SIGN AND DATE TIIE FORM AS INDICAIU). <br /> INSTRUCTION FOR 311E I..00AL AGENCIPS <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 /> II'IS THE RESPONSIB1111.7Y OF 313E IAC'AL AGENCY TIIAT INSPECIN 311E FAC,IIII'Y'I'O VERIFY 31W <br /> ACCURACY OF11IE INFORMATION. Tin!LOCAL AGENCY IS RFSPONSIBI.,E FOR 3IIE COMPIIHION OF 313E <br /> 'LOCAL AGENCY USE ONLY'INFORMNIION BOX AND FOR FORWARDING ONE FORM"A"AND AS,SOCI I'ED <br /> FORM'B'(s)TO 3IiE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> 917MVE WATER RI_SOURCMS CONTROL BOARD <br /> C/O S.W.F F P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9IiM <br />