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INSTRUCTIONS FOR COMPLITIING NORM"B" <br /> GENERAL INSI RUCUONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, RFMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERAW APPLICANT or the IOCAL AGENCY UNDERGROUND TANK <br /> INSPECIIOR <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 rIEM" <br /> 1. Mark an(X)in the box next to the item that best describes the rea&11 the fort is being completed. <br /> 2. Indicate the DBA or Facility name wheree the tank is installed. <br /> L 'LANK DESCRIPTION-COMPLETE ALL rl'EMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID#-If there is a tank=lumber that is used by the owner to identify the tank (ex.AB70789). <br /> B. Indicate the name of the company that m,,,-+e`�.rtured the tank(<:x 'A.CME TANK MFG.). <br /> C. Indicate the year the tank was installed (:x. t9S7). <br /> D. Indicate the tank capacity in gallons(ex. 25,;: or 10,OW etc.). <br /> IL TANK CONTENTS <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&D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUI31,(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&I) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MAT'ER.IAI.„IN'T'ERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORNEATION <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 DMMCTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANIMIX CI.OSI:!)IN PIACI! <br /> 1. ESTIMATED DATE LAST USED-MONTLI/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 INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE 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 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 RESPONSIBH1ff OF TIE,LOCAL AGENCY THAT wswcis, THE FACILITY TO VERITY THE? <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF'ITIF <br /> *LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM"B"(s)TO THE FOLLOWING ADDRESS, <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.F P.& <br /> DATA PROCESSING CI:?NIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 91 M <br /> s - ., <br />