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INSIR.UCIIONS FOR COMPLETING FORM'B' <br /> GFNERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGILS, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGF. <br /> 2. This form should be completed by either the PERMIT'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR <br /> 3. Please type br._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 M24- <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 /> 1. 'TANK DESCIWI70N-COMPLITIti3 All.rITMS-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 /> II. TANK CONIIFNIS <br /> A. L If MOTOR VEIIICI I>FUEL,check box I and complete items B R C. <br /> 2. If not MOTOR VEHICI..E 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 /> 1). 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 CON9I72UCIION-MARK ONE ITEM ONLY IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF SY5"I`EM,TANK MATIRIAI.,, I.'N'TER.IOR I.,INING 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 DI: ITC'I7OiN system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLrI-13CIION <br /> I. Indicate the LEAK DE'ITCTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. IMFORMA770N ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE:LAST USEI)-MONTIIJYEAR(January, 1.9£18 or 01/8.8). <br /> 2. F.SIIMATED QUAN"I'TTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK 1ILLF...I)WITH INERT MATERIAL;?Check'Yes'or'NO'. <br /> APPILCANI'MUST SIGN AND DATE TILTW,FORM AS INDICI\7I1D. <br /> INSTRUCTION FOR 1111E LOCAL AGF.NCIV—S <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 /> rT IS TILE RESI'ONSII3II.LTY OF 1-1113 IOCAL AGiugcY 17IAr INSPtcI'S Tim FAC;II n Y TO VERIFY TuE <br /> ACCURACY OF 11IE INFORMATION. 113E LOCAL AGENCY IS RESPONSIBLE?FOR 111E COMPIL:'I.ION OF'IIIE <br /> 'LOCAL AGENCY USY:ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIA177D <br /> FORM-Br(s)TO TIIE FOLLOWING ADDRESS. <br /> ,W)VIE OIF CALIFORNIA <br /> STA113 WNIT"R RESOURCES CONTROL BOARD <br /> C/o S.W.EI:?P S. <br /> DATA PROC:I:;SSING CEN11?R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90M <br /> '1a 'I .: <br />