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ter„fex 3bf'.i.>: e '�a-, <br /> � s <br /> INSTRUCTIONS FOR COMPLETING FORM-B- <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PEERM11N, PERMIT CHANGES, REMOVAIS and/or any <br /> other TANK INFORMXIION CIIANGE. <br /> 2. This form should be completed by either the PERMIT APPILCANr or the LOCAL AGENCY UNDURGROUND TANK <br /> WSPECrOR. <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:?rn:N- <br /> 1. Mark an(X) in the box next to the iter 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 DESCRIPTION-COMPLETE AIL.ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank II) #-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 /> II. TANK(X)NIVNIS <br /> A. 1. If MOTOR VEHICLE FUM..,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 /> 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 CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,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 DI?TF..,C'IION system(s)used to comply with the monitoring requirement for the piping, <br /> V. TANK IEAK DE ON <br /> 1. Indicate the LEAK DE`I'ECI'IC)N system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANIMI.Y CIOSI:L)IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MON'I`H/YEAR(January, 1988 or 01/88). <br /> 2. I:;STIMATED QUAN"ITI'Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 1 WAS TANK FILLED W CII I INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE 111E FORM AS INDICATED. <br /> INSTRUCTION FOR TILE 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 /> rr IS TLB?RFSPONSIBILTIY OF THE LOCAL AGENCY THAT INSPI:ICTS THE FAC:II,rIY TO VERIFY TILE <br /> ACCURACY OF 111E INFORMATION. TLLE;;.'CAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE <br /> -LOCAL.AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM"A-AND A.'S.SOCIA.110 <br /> FORM-B-(s)TO TILE FOLLOWING ADDRESS. <br /> STATE OF CAI:LFORNIA <br /> STAID WA'I13R„REsoukcns CONLTtOI,BOARD <br /> C/O S.W.I:.I?P.& <br /> DNIA PROC:'IISSING(1,MITiR <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 9072.3 <br />