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IN91'RUCIIONS FOR COMPLE17ING FORM'B' <br /> Gr EIRAL INSTRUCTIONS: <br /> 1, One FORM"B"shall be completed for each tank for all NEW PERMr1%,PERmrr CIIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2. This form should be completed by either the PERmt-IAPTUCAN17 or the LOCAL AGENCY UNDURGROUND TANK <br /> INSPEM)PL <br /> 3. Please type or print clearly all requested infornfation. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM. *MARK ONLY ONF rM-W . <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 DEW.';RIIYIION-C7OMPLV.rH ALL 17111MS-IF UNKNOWN-So SPFX3FY <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.ACMETANK 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 eta.). <br /> If. TANK CONI11.1117S <br /> A. 1. If MOTOR VEHICLE FUEL, check box 1.and complete items B& C. <br /> 2. If not MOTOR VEHICLY.,"FUEL, check the appropriate box in section A and complete items 11& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VIAIICLE FUEL(if box I 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 Scivice <br /> number), if box I is No,r checked in A. <br /> 111. TANK CONSTMUCIION-MARK ONE rnw. ONLY IN BOX A,B,C&1) <br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PR(YIECIION. <br /> 2. If OTT 1ER,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 OTIIEP,print in space provided. <br /> 1 Indicate the LEAK DETEC711ON system(s) used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DI!I7ECI7ON <br /> 1. Indicate the LEAK DF717(71 11ONsystem(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSES)IN PLACE <br /> 1. K'-.,'I1MA'M,D DATE I.AST USED - MON`III/YEAR(January, 1988 or 01/88). <br /> 2, aSTIMATED QUAN'rrry of HAZARDOUS SUBSJANCE remaining in the tank-(in Gallons). <br /> 3. WAS TANK FILLED W17111 INLIZ71'MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT`MUST SIGN AND DNIV'111E FORM AS INDICAI'LID. <br /> INSTRUCTION FOR'nIE U)CAL AGENC.713S <br /> The state underground storage tank identificatiori number is composed of the two digit county number,the <br /> 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. 'I'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 /> rF 18'HIE RY_1SPONSIBIIXrY OF 11111 1,O(. L AGENCY ITIATINSPIN71'S'11111 FAC11XtT'I7O VI RII'Y 11111 <br /> ACCURACY OI?IllliINK)RMA'IION. 'IIIEI..00AI.AGT,'.NCYISRI.iSPONSIIIII,*1FOR nil,"COMPI.HIION Olz'nll:lI <br /> *LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM W AND AVSOCINIED <br /> FORM'B'(s)TO 111E,FOLLOWING ADDRESS. <br /> STAIT,, OF CALIFORNIA <br /> 91'XIE W)VI'ER RI.—TSOURCES CONTROL BOARD <br /> C/o&W.01Ps. <br /> DA`rA PROCESSING CfWM'R <br /> P.O.BOX 527 <br /> PARAMOUNT",CA 917723 <br />