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INSTRUCTIONS FOR COMPLT?TING FORM'B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NI-.?W`PERMrIS,PERMIT'CHANGES, RE:EMOVAI S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI.ICA.NI'or the LOCAL.AGENCY UNDERGROUND TANK <br /> INSPRCTOR. <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 I11.M" <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 /> L TANK DESCRIP11ON-COMPIPSIZ ALL HEMS-IF UNKNOWN-SO SPECIFY" <br /> A. Indicate owners tank Ill# -If there is a tank number that is used by the owner to identify the tank(ex.A11.70789). <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 CON17I:39IS <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 i is checked in A). <br /> D. Print the chemical name of the ha72rdous 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 LINING and CORROSION PROTIACIION. <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 TEC'11ON system(s) used to comply with the monitoring requirement for the piping. <br /> V. 'TANK LEAK DETFC11ON <br /> 1. Indicate the LEAK DEFECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEIVI'LY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST'USED-MONI'l-I(YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANIITY of IIA'I..ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or WO'. <br /> APPLICANT MUST SIGN AND DNI17 IIIE FORM AS INDICATED. <br /> ). <br /> INSTRUCTION FOR TIIE LOCAL AGINC1IS <br /> The state underground storage tankk 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 fbrtn "A". T'he <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 TM!RFSPONSIBRXI Y OF TEIE LOCAL AGENCY 1TIAT INSPECIN THE FACILITY TO VERIFY TEIE <br /> ACCURACY OF TIIE INFORMATION. 711E I.00AI,AGENCY IS RESPONSIBIJi FOR 111E COMPLETION OF TIIE <br /> 'LOCAL AGENCY USE ONI Y•INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM-W(s)1.0 THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAT13 WATER RESOURCES CONI'ROI.BOARD <br /> C/O S.W.E.S?P.S. <br /> DATA PROC 17SSINCY C WtER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90713 <br />