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INSI'RUCI`6M)pOR(:OWAG G FORM"B" <br /> C TMIRAL INSTMUC.TIONS: <br /> 1. Oise FORM"B"shall be completed for each tank for all NEW PERMrm PERMIT C lIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMrT APPI1CANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <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 DESCRIPTION-COMPLETE ALI,MWS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank number tb%t 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 CONTENTS <br /> A. 1.If MOTOR VEHICLE 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. 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 Sc,vice <br /> number),if box 1 is 14OT checked in.A. <br /> III. TANK CONSTRUCTION-MARK ONE rITW ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL...,INTERIOR LINING and CORROSION PROTECTION. <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 DETECI1ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHIE I'ION <br /> 1. Indicate the LEAK DE'T'ECCION system(s)used to comply with the monitortng requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CEASED IN PLACE <br /> 1. FSI'IMATED DATE I..AST USED-MONI'IJ/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WPI:1I INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> IN.SI'RUCTION FOR TME 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 (91.6)739-2421. 7'he 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 TITS RESPONSIBIIXff OF T1111 LOCAL AGENCY Z.1IAT INSPECTS 7.11E FACILITY TO VERIFY TLII:? <br /> ACCURACY OF 111E INFORMATION TIIE IACAL AGENCY IS RESPONSIBLE FOR 11111 COMP1.E710N OF THE <br /> "LOCAL AGENCY USE ON Y"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOGS 'INIED, <br /> FORM"B"(s)TO rIIE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> b'TATF WA113R RESOURCES CONTROL BOARD <br /> C/O&W.Lx_nP& <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />