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-7 <br /> INSTRUCTIONS FOR CMPLEILING FORM"Ir <br /> GENERAL INSTRUCTIONS- <br /> 1. One FORM "B"sball be completed for each tank for all NEW PERMITS,PERMIT CILANGES, REMOVAUS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2, This form should be completed by either the PERMIT APPLICANT or the LOCAL 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 /> TOP OF FORM:'MARK ONLY ONE ITEM' <br /> 1. Mark an (X) in the box next to the item that best describes the reason the fora is being completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK DESC.RIP`I7ON-COMPLEIM All,M12AS-IF 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.A1370789). <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 CONT12M, <br /> A. 1, If MOTOR VEHICLE 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 &1.). <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 /> III. TANK CONSIRUC11ON-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OFSYS`JT',M,TANK MA'I'ERIAL,INFERIOR LINING and CORROSION PROTEX:rION. <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 OTIIER,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 DETEC`I1ON <br /> 1. Indicate the LEAK D1-:4'TECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON'TANK PERMANEM17Y CLOSAID IN PLACE <br /> 1. ESTIMATED DATE, LAST USED-MONI1I/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of RAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wri-ii INERT MAIT-RIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATH'ITIE FORM AS INDICATED. <br /> INSTRUCTION FOR TIEF LOCAL AGEN('1ES <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 REsPomsuitury OF 111E LOCAL AGENCY 11WFINSPECIN 71117.FACILITY'1'O VERI1l-`Y'11IE <br /> ACCURACY OF'I1IE INFORMATION. TI.W-LOCAL AGENCY IS RESPONSIBLE FOR TITE COMPLHIION OF11111 <br /> "LOCAL AGENCY USE ONLY-INFORMATION BOX AND FOR FORWARDING ONE FORM W ANb ASSOCIATED <br /> FORM'B'(s)TO FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STKIMI WATER RESOURCP-S CONTROL BOARD, <br /> C/o Sxxmps. <br /> DATA PROCESSING c-Lwn-;R <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 90723 <br />