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0 <br />INSTRUCTIONS FOR COMPLU17ING FORM *B* <br />GI NERAL INSTRUCTIONS: <br />0 <br />1, One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT QMKGFS, REMOVALS and/or anv <br />other TANK. INFORMA711ON CHANCY13. <br />2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br />INSPFA-I'OP- <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 IT WO I <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 9r. Facility name where the tank is installed. <br />1. TANK DESCRIVI'ION -COMPLEWE ALL ITEMS - WUNKNOWN - SO SPECIFY, <br />A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (M 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 />11. TANK CONIENIN <br />A. 1. If MOTOR VFMICLE FUEL, check box I and complete items B & C. <br />2. If not MOTOR VEHICLE 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 VEIIICLE FUEL (if box 1 is checked in A). <br />D. Print the chemical name of the hamirdous substance stored in the tank and the CA.S.#. (Cheinical Abstract Service <br />number), if box I is NOT checked in A. <br />III. TANK CON!;FRUC-17ION - MARK ONE? r.n?M ONLY IN BOX A, B, C & D <br />1. Check only one item in'I`YPE OF SYSTEM, 'TANK MAI'ERIAL, INTERIOR LINING and CORROSION PROTEC7110M <br />2. if on-im print in the space provided. <br />IV. PIPING INFORMATION <br />1. C`ircic A if above ground; circle U if underground; and circle both if applicable. <br />2. If UNKNOWN, circle; or if OTHER, print in ,pace provided. <br />3. Indicate the Lr!AK DYSI'ECTION systern(s) used to comply with the monitoring requirement for the piping. <br />V. TANK U!AK DI?IrX-*nON <br />1. Indicate the LEAK D1371"ECTION system(s) used to comply with the monitoring 1-c!p1rements, for the tank, <br />VL INFORMNIION ON TANK PE RMANEN11LY CLOSED IN PLACE <br />1. EII"IIMATED DATE IAS1` USED - MONTII/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITII INERT MA11RIAV Check 'Yes' or'NO'. <br />APPLICAMI'MUST SIGN AND DATE 111131 FORM AS INDICNIMI). <br />IN1,';rRIJCnON FOR'nIF. LOCAL AGPINCIPS <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 he 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 IS1711111 RF-SPONSIBIIXI"Y OF 11113 LOCAL AGENCY 7111ATINSPIVIN 11111 FACILITY '11O VERII-VITHi <br />ACCURACY OF 111E 114FORMAIJON. '111E IX)CAL AGENCY IS RESPONSIBLE FOR'111[li COMPLIqION OF 11111 <br />*LOCAL AG04CY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM 'A7 AND ASSOCIATE <br />FORM '11'(S) 1-0 THE FOLLOWING ADDRESS. <br />STATE OF CALIFORNIA <br />STATE WATER RF-SOURCM' CONTROL BOARD <br />C/o S.W.F-11-P.& 1, - :-I I f <br />DATA PROCISSING CYWMIR <br />P.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />0 <br />