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INSI'RUCIIONS FOR C'OMPLI'.rING FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERM17I1S,PERMrr CHANGI_S, REMOVALS and/or any <br /> other'TANK INFORMATION C'IIANGF <br /> 2. This form should be completed by either the PERMIT'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INS7PECI'OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> T`OP OF 17ORM:'MARK ONLY ONE rrr-,M* <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 DESCRIPTION-C OMP111,1TZ All.rl1?MS-IF UNKNOWN-SO SPF.CUJ'Y <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 /> IT. TANK CONIT?NTS <br /> A. 1. If MOTOR VELIICLI33 F'UEI.,,check box 1 and complete items B R C. <br /> 2. If not MOTOR VEHICLE FUEiL,check the appropriate box in section A and complete items 13 K. 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 /> 111. TANK CONSTRUCTION-MARK ONE III3M ONLY IN IIOX A,13,C&D <br /> 1. Check only one item in'I YPE OF SYS I U-M,'TANK MATERIAL, LNTI'ERIOR LINING and CORROSION PROTEC,`I"ION. <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 OTEIEIt,print in space provided. <br /> 3. Indicate the LEAK DII'EiCI1OfN systems) used to comply with the monitoring requirement for the piping. <br /> V. 'TANK I,F.AK DEI73C'I7ON <br /> I. Indicate the LEAK DFA7EC`'IQN system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PIIRMANINII.Y CI.OSF.D IN PI.AC3 <br /> 1. FS"I7 tLA77 iD DATE LAS-I'USED-MO N nI/YEAR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANl.'I'IY of I-IAI,AItDOUS SU13SI'AN(-'.E remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WrIll INMRT Mr'-'I'ERIAL?Check 'Yes'or'NO'. <br /> APPIdCANr MUST'SIGN AND DATT117lF,FORM AS INDIC:A1111). <br /> IN,SI'RUCriON FOR TIIE LOCAL AGENC'IFS <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 tie 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 /> rr IS 111E RFSPONS1131.1.11 Y OF 71113 LOCAL AGI Ncy 77IA'r INSPE,CIS n n.;FAC:Iary TO VERIFY'I1TE <br /> ACCURACY OF 11M INFORMAZTON. ITIE LOCAL AGHNC,'Y IS RESPONSIBIX1 FOR1111?COMPLETION OF 111E <br /> "I.00:AI.AGENCY UST:?ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSO(7)VI7 D <br /> FORM"B'(s) M 111E3.FOLLOWING ADDRIS.S. <br /> STMT OF CALIFORNIA <br /> S1A77?WA7.7:sR RESOUR(:ES CONTROL BOARD <br /> C/O S.W_IL11 P S. <br /> DA'1A PROCENSING CTW17?R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90723 <br />