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INSTRUCTIONS FOR C:OMPLETFNG FORM"I3` <br /> GENERAL IN9FRUC` ONS: <br /> i. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGFS, REMOVALS and/or any <br /> other TANK INFORMAi1ON CIIANGF- <br /> 2. This form should be completed by either the PERMrI'APPI1CANT or the LOC:.AL,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 /> I. Mark an (X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate tate DBA or Facility name where the tank is installed. <br /> I. TANK DFSC:RR'I1ON-C'OMPLM`E All.ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank I1) #-If there is a tank number that is used by the owner to identify the tank (ex.A1370789). <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.2.5,000 or 10,000 etc.). <br /> 11. TANK CONE1WIN <br /> A, 1. If MOTOR VEHICLE FUEL,check box 1 and complete items T3& C. <br /> 2. If not MOTOR VEHICLI. FUEL,check the appropriate box in section A and complete items I3& D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEI-IICLE,FUF L(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 i is NOT checked in A. <br /> III. TANK CONSTRUC110N-MARK ONE ITI. E ONLY IN 13OX A,E3,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PRO'F13CI1ON. <br /> 2. If O11Ifik print in the space provided. <br /> IV. PIPING INFORMA710N <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 DLTFC CION sytiem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI.I`EC'IION <br /> 1. Indicate the I..TiAK T)I'TF.,CT'ION sytem(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMAIION ON TANK PERMANENII.Y CLOSTI)IN PLACE <br /> 1. ES11MA"IED D<A'I'E I.AST USED- 4iON111/YE,AR (January, 1988 or 01/88). <br /> 2. FSI'IMATED QUANTITY of HAZARDOUS SUBSTANCF remaining in the tank(in Gallons). <br /> 3. WAS TANK FIL,LFD WITH INERT MATT RIAL? Check'Yes' or'NO'. <br /> APPLIC:ANT MUST SIGN AND DA11?"F'IIE FORM AS INDICAI2?D. <br /> INSTRUC:'TION 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 digin 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 /> TT ISTHE RUSPONSI1311 TTY OF 17IE LOCAL AGENCY 1TIAT INSPECTS 111E I?AG7IXI'Y'I`O VERITY 11111 <br /> ACCURACY OF THE INFORMATION. 11IE LOCAL AGENCY IS RI SPO'NSIBI.I?FOR TIIE COMPLL?I'ION OF TITE <br /> 'WCAL AGI:7NC"Y USE ONLY'INFORMATION BOX AND FOR FORWARDING;ONE FORM"A"AND ASSOC WIVD <br /> FORM"Ir(s)TO-11111 FOLLOWING ADDRESS. <br /> SI:AITI OF CALIFORNIA <br /> STATE WAIT R RESOURCES CONTROL BOARD <br /> DATA PROCESSING CEMI1?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />