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i <br /> INSTRUCTIONS FOR COMPLIG FORM-Ir <br /> C,EM:?R .L INSMUCTIONS: <br /> 1• One FORM"B"shall be completed for each tank for all NEW PERMrM PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION C RANGE. <br /> 2.. This form should be completed by either the PIRWr APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> IN.STECrOR <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 OF FORM:*MARK ONLY ONE ITEM" <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.SC'RIP710N-COMPLUM,ALL,11WAS-W 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 /> IL TANK CONI'FM:S <br /> A. 1.If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLE FUFT.,,check the appropriate box in section A and complete items B& D. <br /> B. Check the appropriate box. <br /> C. Cheek 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 Seivice <br /> number),if box 1 is;10T checked in.A. <br /> 111. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&I) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROT"EC170N. <br /> 2. If OTHER,print in the space provided, <br /> LV. 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 DETF,CITON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I i?AK.DETF)C1ION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANI.7MLY CLOSED IN PLACE. <br /> 1. ESTIMATED DATE LAST USED-MONITj/YEAR(January, 1988 or 01/88)..,. <br /> 2. ESTIMATED QUANTITY 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 DATI1 111E DORM AS INDICATED. <br /> INSTRUCTION FOR THE 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. '!'he 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 /> IT IS THE RESPONSIBILITY OF 1IILi LOCAL AGENCY THAT INSPECCS T'I IE FACT PTY'T[)VERIFY THE <br /> t <br /> ACCURACY OF THE,INFORMATION. THE I CXAI,AGENCY IS RISPONSIBL F FOR TTIE COMPLETION OF THE <br /> "LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOC'IAT'ED <br /> FORM-Br(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE.WATER RESOURCES CONTROL BOARD <br /> C/O S•W.F-L?Ps. <br /> DATA PROCESSING CENTII3R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />