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INSI.RUCITONS FOR COMPLTFITNG FORM"Ir <br /> GENERAL INSMUCTION& <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PI?RMIT CTIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the IDCAI.AGENCY UNDF.,RGROUND 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 IITa2I" <br /> 1. Mark an (X) in the box next to the item that best describes the reason the forst is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> 1. TANK DESCRIPITON-COMPId3TE All,!1'TWS-IF UNKNOWN-SO SPF.CIF'Y <br /> A. Indicate owners tank 1D #-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 CONTENTS <br /> A. 1. If MOTOR VEIiICL,E FUEL,check box 1 and complete items B R C. <br /> 2. If not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B& D. <br /> 13. Check the appropriate box. <br /> C. Check the type of MOTOR VEIJIC I,E FUEL(if box 1 is checked in A). <br /> I). 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 CONSIRUCITON-MARK ONE mm ONLY IN PA)X A,FI,C&D <br /> 1. Check only one 'item in TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR I.,INING and CORROSION PROT'ECI'JON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMA170N <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OT'FIER,print in space provided. <br /> 3. Indicate the LEAK DI;ITCIION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LFAK DE TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANINII:,Y C:I,OSED IN PLACE <br /> 1. ES11MA7I1D DATE UMSTUSED-MO.%7'II/YF.AR(.January, .1988 or 01/88). <br /> 2. ESTI4IATED CHUAN 'TIY of HAZARDOUS SUBST'ANC.E remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WTI"I-I IitiER':I'MA'IT3RIAI.? Check 'Yes'or INO'. <br /> APPLIC:ANI'MUST SIGN AND DATE111F,11F,FORM AS IMXC AT ED. <br /> INSIRUC'TION FOR 7.1IE IAC'.AI,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 (916)739-2421. The facility number must be the same as shown in form "A". 'ne <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 TUE RF.SPONSI131:I1I7Y OF TTIE LOCAL AGENCY mA'T INSPF,CIS um fzACTLIT'Y TO VERIFY,nil? <br /> ACCURACY OF'I1JE INFORMN17ION. THE LOCAL AGI.NC.'Y IS RESPONSIBLE FOR TIIE COMPI.I?TTON OF'ITTi's <br /> "IA)C'AL AGENCY USE ONLY"INFORMATION I3OX AND FOR FORWARDING ONE FORM'A"AND ASSC)CIA110 <br /> FORM'B'(s)'1`0 TUE I OLJ OWING ADDRI?SS. <br /> STATE OF CAIJFORNIA <br /> SI'AI'E WA'1T:iR RESOURCES CONIROI.BOARD <br /> C/O S.W.IiI:r P.S. <br /> DATA PROCESSING C'IXIT?R <br /> P.O.13OX 527 <br /> PARAMOUNT,CA 90M <br />