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xw <br /> TNSTRU(NIONS FOR COMPLEUING 17ORM'B* <br /> GENERAL IN,51.'RU(.'IIONS- <br /> L One FO%M "B"shall be completed for each tank for all NFW PERMM,.,PFRMTI'(-,11ANGF-S, REMOVAUS and/or any <br /> other TANK INFORMATION CHANGE 11*4 <br /> 2, This form should be completed by either the PERMTI"APPLICAN17 or the WCAL AGENCY UNDFRGR0UNDTAMC. <br /> INSPIXXOR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,yQu arc,making 3 copies. <br /> TOP OF IX)RM: *MARK ONLY ONE TIMM* <br /> 1. Mark an (X).in the box next It) the item that best describes the reason the form is being completed. <br /> 2. Indicate the D13A or facility name where the tank, is installed. <br /> I. TANK DESCRIFFION-COMPLE171 All,-FITALS-H?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 /> 13, Indicate the name of the company that manufactured the tank(ex.ACME TANK MFG.). <br /> C, Indicate the year the tank was installed (ex. 1(987). <br /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> It TANK(X)MITWf',S <br /> A. 1. If MOTOR VUlIICLL'f,UFL,check box I and complete items B& C. <br /> 2.If not MOTOR VEIIICLF FUE1.,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 CONS-IRUC717ON-MARK ONE rlEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item ire l.-YPF,'01,'SYif'FM,TANK MATERIAL,INITRIOR LINING and CORROSION PROTEX.7110N. <br /> 2. If OTIIFR,print in the space provided. <br /> IV� PIPING INFORMXIION <br /> 1. Circle A if above ground;circle U if underground: and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTHE3R,print in space provided, <br /> 3. Indicate the LEAK DE-114"C HON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK 113AK DHII?C'ION <br /> 1. Indicate the LEAK DLI'FC.HON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMSHON ON TANK PERMANFNII.Y(3,OSED IN PI-ACF I ?P7 <br /> I. EF11MATED DATE LAST USED-.AY1O11,-nI/YFAR(January, 1988 or 01/88). <br /> 2. LS-11MATED QuA.rvrriy of ifA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANk FILLED WITH INERT MA'11'zRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND D)VII!11W,FORM AS INDICKITI), <br /> INSTRUCTION FOR*11 IE 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 number-,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 ITIS RUSPONSIBILTI'Y OFflIE LOCAL AGENCY TIIXf INSPECTS'17111i FACILTYY'M VERIFY IIIc? <br /> ACCURALY OFTIIE INFORMA11ON. '1111, LOCAL AGENCY IS RESPONSIBLE*FOR IIIE COMPIErnON OF ITIS <br /> .IA)(:, L AGENCY USE ONLY"INIX)RMIVIION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIW[ED <br /> FORM'B'(s)TO 11IR FOLLOWING AI)DRH%,& <br /> SI:1VIT'OF CALIFORNIA <br /> 91'XIV WNIER RE-SOURCHS CONTROL BOARD <br /> C/O <br /> DATA PROCI:,SSING CENTI!R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />