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INSTRUCIIONS FOR COMPIHIAORM'B" ' <br /> GEM 1RAI,INS1RUCTTONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PI RMI S,PERMrr ctIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMETAPPLICANI'or the LOCAL.AGENCY UNDERGROUND'TANK <br /> INSPECL'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 /> TOP 017 FORM:"MARK ONLY ONE rl.lW* <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 /> 1. 'PANIC DESCRIPTION-C OMPI UM4 All.rlEMS-IF UNKNOWN-SO SPE:C[FY <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 /> LL. TANK CON`11WrS <br /> A. 1. If MOTOR VEIIICL;Ei 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 /> B, Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE 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 II'E:?M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROT`ECfTON. <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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DEFECTION sysiem(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DL7II?CIC ION <br /> 1. Indicate the L,E:.AK DE"I'ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMNIION ON TANK PE.RMAN1.WI7LY CLOSED IN PLACE; <br /> 1. ES'TIMAT'ED DATE LAST USED-MONTIL/YEiAR(January, 1988. or 01/88). <br /> 2. ESTIMATED QUANTTT'Y of H,AZARDOUS SUBSTANCE remaining in the tank(in Gallons). ti <br /> 3. WAS TANK FILLED WITH INERT MA'T'ERIAL.? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATL 11111 FORM AS INDK ATT?D. <br /> INSTRUCLION FOR 11111 LOCAL AGENCIES <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 /> EI'IS TIIE RFSPONSIBI T17Y OF THIN LOCAL.AGENCY 71IAT INSPECTS THE FAC 11 Y'TO VERIFY THE <br /> ACCURACY 01711113 INFORMATION. TI-IEi LOCA.AGENCY IS RESPONSIBLE FOR TILL:COMP11 1'ION OF TTIE <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND A,SSOC'ItiIT313 <br /> FORM"B"(s)TO".IIIE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAIR WATER RESOURCES CONTROL BOARD <br /> C/O&W.L?F?P.S. <br /> DATA PROCESSING C FWrER <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />