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INSI'RUCIIONS FOR COMPLETING FORM'B" <br /> GENERAL INS RUCTION& <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMI S,Pl?RMTr CHANGI::S, REMOVAIS and/or any <br /> other TANK INFORMATION CIIANGI3 <br /> 2. This form should be completed by either the PI1RMTT APPLICANT or the I..00AL 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 /> 'IOP OF FORM; "MARK ONLY ONE r11:111" <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 D13A or Facility name where the tank is installed. <br /> 1. TANK DLSC:RIVIION-COMPIdTM?All,r113.MS-IF UNKNOWN-SO SPECIIF'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 /> 11. TANK CONTEN75 <br /> A. 1.. If MOTOR V1?IIICLE 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 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 /> ill. 'TANK CONS7'RUC`I.ION-MARK ONE 1711W ONLY IN BOX A,13,C&D <br /> 1. Check only one item in'TYPE OF SYS'T'EM,'TANK MATERIAL, I:N FE'RIOR LINING and CORROSION PR07 CCHON. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMN11ON <br /> L 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 Dfil'EC I1ON system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I,EAK DI:?`113C-'nON <br /> 1. Indicate the LEAK DE"ITCTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PE.RMANEM11Y CIDSED IN PLAC73 <br /> L E.S11MAI D DATE LAST USED-MONTII/YEAR(January, 1988. or 01/88). <br /> 2. IiSTIMA"TED QUANIFITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS'TANK FILLED WITH INEKI'MATERIAL? Check'Yes'or'NO'. <br /> APPIICANI'MUST SIGN AND DS1111 111E FORM AS INDKCIII.:D. <br /> IN.SIRUCIION FOR 71IF LOCAL AGENCILS <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". 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 RFSPONSIBUX17Y OF T[IE LOCAI,AGENCY THAT INSPECTS TIR FActur Y TO VERIFY'1 w <br /> AC CURACY 01711113.INFORMA7.10N. 1I1E I.O(AL AGENCY IS RESPONSIBLE POR IME?COMPLE'11ON OF`IIIE <br /> "LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIAII?D <br /> FORM-1r(s)TO`11 IF,FOLIAWING ADDRESS. <br /> 11MA1T OF CALIFORNIA <br /> SVVII?WALT R RESOURCFFS CONIROI.BOARD <br /> C/o S.W.L?Fi P S. <br /> DATA PRO('7ESSING CTWIVR <br /> P.O.BOX 527 <br /> PARAMOUNI`,CA 90M <br />