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INSTRUCTIONS FOR(C)MPLOUNG FO 'I3' V <br /> GENERAL INSTRUCTIONS. <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PFRMTI'CIIANGI?S, REMGVAI:S and/or any <br /> other TANK:INFORMATION(:I1. 'GE <br /> 2. This form should be completed by either the PERMTfAPPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <br /> IN,SP 'TOR <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: RK ONLY ONE " <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 /> I. TANK DESCRIPTION-C.OMPLE'Mz ALL ITEMS-W 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 /> B. Indicate the name of the company that manufactured the tank(ex.'ACME TANK MPG.). <br /> C. Indicate the year the tank was installed (ex. 1.187). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> II. TANK CONI ENI'S <br /> A. 1. If MOTOR VEIIICI.J. FUEL,check box 1 and complete items 13& C. <br /> 2. If not MOTOR VEHICLE FUIF.L,check the appropriate box in section A and complete items B c4: D. <br /> & 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 /> III. 'PANT(C0NS'I'RUC`nON-MARK ONE I E° M ONLY IN BOX A,I3,C&D <br /> 1. Check only one item in 'TYPE 01'SYS`T'EM,TANK MATERIAL, IN4 fT'.RIOR LINING and CORROSION PRO'TE?C"110N- <br /> 2. If OTILER,print in the space provided. <br /> IV. PIPING INPGRMA`IION <br /> i 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if O''I EI3,print in space provided. <br /> 3. Indicate the LEAK DF`T1 C7ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK D1nl° `FIGN <br /> 1. Indicate the LEAK DE1'F.CI'ION system(s) used to comply with the monitoring;requirements for the tank. <br /> VL INIAC?RM) PION ON TANK PH',RMA.NE 'I..'I'('I.()SEI)IN PLACE <br /> 1. EFFI TET)I)A'111 LAST USED- MONTIIJYF:AR(January, 1988 or 01./88). <br /> 2. FSTIMA'TEIJ QUAiV'ITFY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS`TANK FILLET) WITH INERT MA'1TRb-\L? Check 'Yes' or'NO', <br /> i <br /> j APPLICANT MUST SIGN AND DA'T'E'IIIE FORM AS IND10VIT0. <br /> INSTRUCTION FOR 11111 LOCAL AGI3NCTES <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". <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 /> 1'I`IS"I IIIA RFSP? NS111111I'Y OF77M 7M LOCAL AG CY'ITIAT INSPEC'IN TUR PACILTI'Y'TO VERIFY TIII1 <br /> AC(:13RA('Y OI?'17113�IORMNI'TON. T ITS LOCAL AGE CY IS x.SPONSIBIZ?FOR TIIE CO.MPII-7,TION OF TTIE <br /> "LOCAL AGENCY USP ONLY"IEVT'C)T MN17ON BOX AND FOR FORWARDING ONE IDRM"A"AND ASSOCIA"Cl?D <br /> F(A4 M"11's) O"1-1`s s', '1 1..OWING AI)DRES& <br /> S`I`AI "OF(W IFORNIA <br /> SI'A°IE WXI ''R RESOURCES CONI FOOL.BOARD <br /> C/OW.LrIwI�S. <br /> DATA P€OCR ING C `Nr ER <br /> P.0) )X 52'1 <br /> PARAMOUN I',CA <br />