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,sY._,.;., >.,a¢w.w,^-- ...., d ,- z.,. ,„: ..�,.:,,, :..;., ,. •�*'^.�' .`.t„3«...j:.a.�,:r:.x w.,a A �t>-Ky P'' � �a +"'a` '>�" �.,•-, <br /> INSTRUCTIONS FOR COMPLYING FORM"B" <br /> QENERAL INSTRUCTIONS: , <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3. Please type or print clearly-all requested information. <br /> 0.' 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:'MARK ONLY ONE rTEM' <br /> 1. Mark an(X)in the box next to the item that best dgScribes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK DF—scRII'IION-COMPII3fE AIL,rILMs-II+UNKNOWN-s0 s mcwy t;;a <br /> A. Indicate owners tank IU#-if there is a tank number th9t 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 CONTENTS <br /> A. 1.If MOTOR VEHICLE 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. Cheek 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 Scivice <br /> number),if box 1 is 140T checked in.A. <br /> III. TANK CONSTRUCTION-MARK ONE rins ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATF,RIAL.,INTERIOR LINING and CORROSION PROTEC11ON. <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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECCION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACI?. <br /> 1. ESTIMATED DATE LAST USED-MONTIj/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITII INERT MATERIAL? Check'Yes'or'NO'. A <br /> APPLICANT MUST SIGN AND DATE'I•HE FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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 numbers are predetermined and <br /> can be obtained by calling the State Board(915)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 RESPONSLBILM OF TITE LOCAL AGENCY TIIAT INSPECTS THE FACILITY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. THE LOCAI.AGENCY IS RESPONSIBLE,FOR 11IE COMPLETION OF THII <br /> "LOCAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A'AND ASSOCIATED <br /> FORM-B-(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E:3 .& <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> • <br />