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IN91'RUCTIONS FOR COMPIM#FORM#B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMIIN,PFRmrr CIIANGE-S, REMOVALS and/or any <br /> other TANK INFORMA11ON CHANGE <br /> 2. This form should be completed by either the PF.Rmrr APPLICANr or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <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 OF FORM: *MARK ONLY ONE 171122 <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. TANK DESCRIPTION-COMPLE'113 ALL 171MIMS-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 /> 6. Indicate the tank capacity in gallons(ex. 25,000 or 10,000 etc.). <br /> 11. TANK CONTENTS <br /> A. 1. If MOTOR VEIIICLf DUEL,check box 1 and complete items B&C. <br /> 2.If not MOTOR VEHIC1,117 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 VEMICIA"'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 CONS17RUC17ION-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 PROrff7cno.N. <br /> 2. If OT11EIZ, 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 DE-FECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETEC'11ON <br /> 1. Indicate the LEAK DE717ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANI.WI1,Y CLOSED IN PLACE <br /> 1. ESTIMA'11sD DATE LAST USED-MONTII/Y11AR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLET) WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA1L ITIE FORM AS INDICK113D. <br /> INSMUC711ON FOR T.Iff!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 /> ri,is 11111 RESP(.)NSIBH.rff OF 1111!LOCAL AGENCY IlIffir INSPECIN 11111 FACILITY TO VERIFY 1111? <br /> ACCURACY OF'I1IE INFORMKIION. 1111!LOCAL AGENCY IS RESPONSIBLE 17OR 311E,C OMPIHI1ON OF 11113 <br /> 'LOCAL AGENCY USE ONLY"INFORMNIION BOX AND FOR FORWARDING ONE FORM *A*AND ASSOC.INIV.D <br /> FORM -Ir(s) M-11111.FOLLOWING ADDRESS. <br /> STNII!OF CALIFORNIA <br /> SFNMI W)VILIR RESOURCES CONTROL BOARD <br /> C/o&w.u-E.P.S. <br /> DATA PROCESSING CENIER <br /> P.O.13OX 527 <br /> PARAMOUNT,CA 90723 <br />