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�C <br /> INSIRUCIIONS FOR COMPLIF.TING.FORM"B" <br /> GENERAL INSLRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGES, REMOVALS and/or any <br /> other TANK INFORMAITON CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LACAL 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 ITIiM' <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 DESCRIPTION-C'OMP113III AI1,I1171AS-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 CON11WIS <br /> A. L If MOTOR VEHICLE FUEL,check box I 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. 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 /> M. TANK CONSTRUCTION-MARK ONI?PI1?M ONLY IN BOX A,11,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION PROI7ECI10N. <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 QTHM print in space provided. <br /> 3. Indicate the LEAK DUFF- TION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEI1?CIION <br /> 1. Indicate the LEAK DE7ECT10N system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANPNI LY CLOSED IN PTAC? <br /> 1. ESTIMATED DATE LASTUSED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANITTY of HAZARDOUS SUBSTANCE remaining in'the tank(in Gallons). <br /> 3. WAS TANK FILLED WTTII INERT MATERIAL?Check'Yes'or'NO'. <br /> APPIICANT MUST SIGN AND DATE TIIE?FORM AS INDICATED. <br /> INSTRUCTION FOR TIII?LOCAL AGENCIES <br /> Ehe 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 RESPONSIBILITY OF 17111 LOCAL AGENCY ITIAT INSPECI.N 11IE FAC:II.r1'Y TO VERIFY 1711E <br /> ACCURACY OF'111E INFORMATION. 11IB LOCAL AGENCY IS RESPONSIBLE FOR IIID COMPLHI.ION OF[TIE <br /> "LOCAL AGENCY USE ONLY*I.NPORNINHON BOX AND FOR FORWARDING ONE DORM'A"AND AS,SCX7A113D <br /> FORM'B'(s)TO TIIE FOLLOWING ADDRIM. <br /> STATE OF CAI LFORNIA <br /> SI'ATL?WATER RESOURCES CONIROL BOARD <br /> C/O S.W.Iinp s. <br /> DATA PRO(7''NSING CIwmR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> • <br />