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INSTRUCTIONS FOR COMPI.1-FI �I�;ORM'B' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B" shall be completed for each tank for all NEW Pl?RMII'S,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 AGENC'Y UNDE GROUND TANK <br /> INSPM1OR. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. i <br /> TOP OF FORM: "MARK ONLY ONE.117.11W <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 /> I. 'TANK DI?SCRIP'lTON-C:OMPIJ.rl'E ALI.ITEMS-lir UNKNOWN-SO SPIX IFY <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 /> H. 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 /> 13. Check the appropriate box. <br /> C. Check the type of MOTOR VEiHICL,I 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 Sen--ice <br /> number), if box 1 is NOT checked in A. <br /> I11. 'TANK CONSTRUCTION-MARK ONE ITIS ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING; and CORROSION PROT ClION. <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 DUMANION <br /> 1. Indicate the LEAK DT'I'ICTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMN11ON ON`TANK PERMANEMILY CU)SED IN PLACE <br /> 1. ISTIMA'ITD DATE LAST USED-MONTIT/YI.AR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IWARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or'NO'. <br /> APPIJC ANE'MUST SIGN AND DA1E 11113 FORM AS INDICATED. <br /> INS-MUCIION 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 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 /> II'IS THE RESPONSIBILITY OF T11E LOCAL AGENCY THAT INSPI:TIN TI IE FACIITI'Y'L'O VE RIF'Y'II-1E <br /> ACCURACY OF IIIE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 1.11E COMPIX.I'ION OF TE1F <br /> 'LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM'B"(s)TO'11111 FOI1,OWING ADDRESS. <br /> STNIE OF CAIJFORNIA <br /> STA7111 WATER RI-SOURCES CONTROL BOARD <br /> C/o&W.LEP,S. <br /> DATA PROaS.SING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />