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INSTIRUC'ITONS FOR COMPLHIING FORM*B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMr][S,PERMIT Cl-LANGF-S, 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 pointwritinginstrument,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 form is being completed. <br /> 2. Indicate the D13A or Facility name where the tank is installed. <br /> 1. TANK DF—SCRIVITON-COMPII:M?All,TrEMS-IF UNKNOWN-SO SPIXXzY <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 /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. TANK a)NrfWrS <br /> A. L If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VE111CLI.,.' 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 I is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> HL TANK CON,5l'RUC!11ON-MARK ONE n-EM ONLY IN BOX A,11,C&D <br /> 1. Check only one item in'TYPE OFSYS`.I'EM,TANK MA'IERIAL,INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING M?ORMAITON <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 DLrrFk'I.TON <br /> L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> V1. INFORMATION ON TANK PERMANFNITY CLOSED IN PIA(V <br /> 1. ESTIMA'IT-.D DATE LA5I'USED-MON`l-II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INfXr MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 71111 FORM&S INI)]VATM. <br /> INSTRUCTION FOR TME IOCAL AGENCIES <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 /> rr is TuE RESPONSIBILITY OF ITIE IX)CAL AGI.T40f TI IAT'INSPECTS'111E FACHlTY TO Vlr--RH,'Y'IIIE <br /> ACCURACY OF TITE 11-4FORMN110N. TIHSJAX:AL AGENCY IS RESPONSIBLE FOR-nIE COMPLHIION OF'111E <br /> "WCAL AGENCY USE ONLY'IN[FORM)VI10N BOX AND FOR FORWARDING ONE FORM'A*AND ASSOCINITI) <br /> FORM'B'(s)TO-11117,FOLLOWING ADDRESS. <br /> -STATEI 017 CALIFORNIA <br /> `;FX17111 WATER RESOURCES CONTROL BOARD <br /> C/o S.Wluips. <br /> DNA PROCV-&SING CLWR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />