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INSTRUCTIONS FOR COMPLIIIING FORM"B" LTi <br /> GENERAL,INSTRUCTIONS: <br /> 1. One FORM"L3"shall be completed for each tank for all NEW PE?RMZTS,PERMIT C.'IIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGIL <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGI?NCY UNDERGROUND TANK <br /> INSPECIX)R <br /> 3. Please type or print clearly all requested information. <br /> d. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM: "MARK ONLY ONE 1112T <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 DESCRIPTTON-COMPLETE AI.I.11'EMS-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 CONTENTS <br /> A. 1. If MOTOR VEHICL13 FUEL.,check box 1 and complete items I3&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 VEHICI.,I 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 Semice <br /> number),if box I is NOT checked in A. <br /> III. TANK CX)NSTRUCIION-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 PRO'TECL70N, <br /> 2. If OTHEIZ,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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I,EAK DEWX:110N <br /> 1. Indicate the LEAK DEITCTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANIN11M(I.OSED IN PLACE <br /> 1. ESTIMAIT.D DATE LAST USED-MONTH/Y1IR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIAIARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL.? Check 'Yes'or'NO'. <br /> APPIdC7tM'MUST SIGN AND DATE T11E FORM AS INDI(WI'FD. <br /> II�NMRUC'IION FOR 711E LOCAL AGENC"IFS <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. 17he 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". Tlie <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 /> IT,IS IIID RESPONSIBILITY OF THE LOCAL AGENCY TIIAT INSPI'=C15 TILE FACILITY TO VERIFY TIIEr <br /> ACCURACY OF'I1IE INFORMATION. TIIE LOCAL AGENC.'Y IS RESPONSIBI.I?FOR TIIE COMPI.d11ON OF TTIE <br /> 'LOC:AL..AGENCY USI:ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> 110RM "B"(s)TO IIIA FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAII:WRIER RELSOURC:II-S C'OMILOL BOARD <br /> C/O S.W.ILE.P.S. <br /> DATA PROCESSING C:WfF.R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />