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INSIRUCIIONS FOR COMPLUIING FORM'B' <br /> GENERAL.INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMPIs,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGI? <br /> 2. This form should be completed by either the PERMrr APPLICANT or the I..00'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 MN* <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 DFSCRIP'IION-CY.)Mmum ALL rrI3MS-W 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 VEITICI.,E FUEL,check box 1 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 /> III. TANK CONSI'RUCIYON-MARK ONE HEM ONLY IN BOX A,13,C&D <br /> L Check only one item in TYPE OF SYSTEM,TANK MATI3RIAL, INIER.IOR I.,INING and CORROSION PROTECTION. <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 UNKNOWN,circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DEIECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUIUCI'ION <br /> 1. Indicate the LEAK DF'IT,CTION system(s)used t8 comply wiihe monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE? <br /> 1. ES'IIMmip DAI'f:3 LAST USED-'vlOrsMIjYEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANT'IT'Y of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WPTI-I INERT MA'T'ERIAL;? Check'Yes'or'NO'. <br /> APPI ICANt'MUST SIGN AND DATE111E FORM AS INDI(117I11). <br /> INSTRUCTION PORTHE HE 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'sixsiigit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (91739-2421. The facility number must he 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 RESPONSIBI M OF'IIIE LOCAL AGENCY THAT INSPECI:S TIIE FACII,I'Y TO VERIFY THE <br /> ACCURACY OF T1IF:INFORMATION. IIIE LOCAL AGENCY IS RESPONSII3I.E FOR TIIE COMPLETION OP TIIE <br /> *LOC'AL AGENCY US13 ONLY'INFORMA11ON BOX AND POR FORWARDING ONE FORM'A'AND ASS(XIAII?D <br /> FORM"B"(s)TO I11E FOLLOWING ADDRIM <br /> STAR;OF CALIFORNIA <br /> STATE?WATER RESOURCES CC)IYI'ROL BOARD <br /> C/O S.W Ii PS. <br /> DATA PROCESSING CI'.`MT R <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 900 <br />