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INSIRUCTTONS FOR COMPLETING.FORM"B" ' <br /> GFNERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGI.S, REMOVALS and/or any <br /> other TANK INFORMA71ON C'HANGIE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDF,RGROUND 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 17ORM:*MARK ONLY ONE I112A* <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 DFSCRIP'ITON-C:OMPT.H171 ALL r.tI MS-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 /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 11. TANK CONTENTS <br /> A. 1 If MOTOR VIITICLI FUEL,,check box 1 and complete items B &C. <br /> 2. If not MO'T'OR VEHICLE 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 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 Service <br /> number), if box 1 is NOT checked in A. <br /> III.• 'TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL.,, INTERIOR 1.1NING and CORROSION PROTEcriON. <br /> 2. if OTHER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNXNOWN,circle; or if OTFIF_It,print in space,provided. <br /> 3. Indicate the LEAK DE-FEC'IION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI?IECTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CI OSF.D IN PLACE <br /> 1. ESTIMATED DATE LAST USF...D-MONTII/YEAR(January, 1988 or 01/38). <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 DATE'11TE FORM AS INDICATED. <br /> IN,STRUCITON FOR TIIE 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 /> IT IS THE RF.SPONSIBII TTY OF TILE LOCAL AGENCY TIiAI'INSPECTS Tim FAC:II.ITY TO VERIFY THE <br /> ACCURACY OF 171E INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPL.EI.ION OF'TIIE <br /> "LOCAL AG.FNCY US14 ONLY'INFORMATION BOX ANI)FUR FORWARDING ONE FORM A"AND ASSOCIATED <br /> FORM'B"(s)TO T1TE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> SI'AIE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.I+Er PS. <br /> DATA PROCESSING C'INII?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90773 <br />