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INSPRUCIIONS FOR COMPLITI ING FORM"W <br /> GENERAL INSTRUCHONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT C"HANC,I?S, RUMOVAI S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT'or the I..00AL 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 thnt best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> L TANK DESCRIPTION-COMPLETE ALL ITEMS-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 wa7-,aa`-poured the tank(cy 'S.0.11E TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 3.987). <br /> D. Indicate the tank capacity in gallons(ex. 2.5, t:r-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.VF:IIICLE 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 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. Cheek 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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY CI. X99)IN PLACE <br /> 1. ESTIMATED DATE IASI'USED-MONI 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 WTTII INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DAT[?'1111:11 FORM AS INDICATED. <br /> INSTRUCTION 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 fonts"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 /> 1T IS TIIE RESPONSIBum OF Tm LOCAL AGENCY THAT iNspEcIsTIIE FAc"ff TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. TME LOCAL AGENCY IS RES'PONSMI E FOR THE COMPLETION OF THE <br /> 'I.00AI.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM'B'(s)TO T'IIE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.E.P.S. <br /> DATA PROCESSING 0!NrER <br /> P.O.BOX 527. <br /> PARAMOUNT',CA 90M <br />