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7177779T7 <br />F7 <br />0 <br />INSITtUCIIONS FOR COMPLETING FORM "B" <br />GENERAL INS`TRUC-nONS: <br />L One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CTIANG04S, REMOVALS and/or any <br />other TANK INFORMATION CHANGE. <br />2. This form should be completed by either the PERMIT APPLICANT or the IA)CAL 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 ON[z, rM-M* <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 DFSCRW110N - COMPLIUM All. 1711?MS - IF UNKNOWN - So SPF(31?y <br />A. Indicate owners tank It) # - 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 installeO (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 15,000 or 10,000 etc,). <br />IL TANK comn.wis <br />A. 1. If MOTOR VEHICLE FUIEL, check box 1 and complete items B & C. <br />2. If not MOTOR VEIIICLE1 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 VLHICIT, 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 Seivice <br />number), if box 1 is NOT checked in A. <br />111. TANK CONSTRUCTION - MARK ONE ITIM ONLY IN 13,OX A, B, C & D <br />1. Check only one item in 'TYPE OF SYSTEM, TANK MA:IT!.RIAT..,, INTERIOR LINING and CORROSION PROTECIION. <br />2. If O'I'LIER, 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 DHIT"ION <br />1. Indicate the LEAK 1)1-,T'F('I'ION system(s) used to comply with the monitoring requirements for the tank. <br />V1. INFORMATION ON TANK PERMANUNI'LY CLOSED IN PLACE <br />1. F-';'HMNIT-,D DATE I.AST USED - MO1NrI1IJYFAR (January, 1988 or 01/88). <br />2. ESTIMATE].) QUANTITY of I IAZARDOUS SUBSTANCE ' remaining in the tank (in Gallons). <br />3. WAS TANK FILLED Wl'I 1 11 INERT MATERIAL? Check 'Yes' or 'NO'. <br />APPLICANT MUST SIGN AND DA111, TITH FORM AS IND112WIED. <br />INSTRUCTION FOR TME LOCAL AGENCIES <br />The state underground storage tank identificitioA 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. 'phe 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 ISTIIE RESPONSIBILITY OF 1111.1 LOCAL AGENCY'111AT INSP1!C7.rS'I1IE I?ACII.XrY'IX) VERIFY T11E <br />ACCURACY OF TIM INFORMATION. 711E LOCA <br />, 1, AGENCY IS RESPONSIBLE FOR TIIE COMPI.H11ON OF 11111 <br />"CAI, AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCIA7110 <br />FORM 'B'(s) TO -1711E, FOLLOWING ADDRESS. <br />SUVIV OF CALIFORNIA <br />STATE WJVIMR RESOURCES CONTROL BOARD <br />C/o S.W.1.1EP.& <br />DATA PROCESSING CIWI'L?R <br />P.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />