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INSTRUCTIONS FOR COMPII3IING FORM"B" <br /> GENERAL INSI'RUCITONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGF_S, REMOVAI.S and/or any <br /> other TANK IN1X)RMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECMR- <br /> 3. Please type,oy 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 form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK DEI.SCRIVITON C:OMPI.E114,AI..I.TrFMS-IF UNKNOWN-SO SPECIFY <br /> Y <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 CONIVVI'S <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 &I:). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VI!'IIICLE 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 NOTchecked in A. <br /> III. TANK CONSIRUCIION-MARK ONE n`EM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MA'17ERIAL,INTERIOR LINING and CORROSION PROTECTION. <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 DLgVk.'I1ON <br /> I. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANFNI'LY CLOSED IN PLACE <br /> 1. ESI'IMXITED DATE LAST USED-MON]H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WPTII INERT'MATERIAI.?Check'Yes'or'NO'. <br /> APPIICANT MUST SIGN AND DA11?'T11I?FORM AS INDICATED. <br /> INSTRUCIION FOR THE LOCAL 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 /> rT isnm RESPONSII3IL.TLY OF T11E LOCAL AGI:rNC,'Y THAT ENSPECIS TIIE FACILTI'Y TO VERIFY"E1LF: <br /> ACCURACY OF 171E INFORMAVIION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR TIIE C',OMPIHIION OF"IIIE <br /> "LOCAL AGENCY USE ONLY"INFORMA'11ON BOX AND FOR FORWARDING ONE FORINT"A"AND ASSOCIAVII?D <br /> FORM"B"(s)TO TTM FOLLOWING ADDRESS. <br /> STATI?OF CALIFORNIA 'I <br /> STATE WATER RF:SOURCL:S C:ONI'RQI BOARD <br /> C/O&W.m.L P.S. <br /> DATA PROCESSING C:IWI`ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 907L'3 <br />