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INSTRUCTIONS FOR COMPIEnNO FORM *BN <br />GENERAL INSTRUCTIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CIIANGERVM0'Vi,i— <br />other TANK INFORMATION CHANGE <br />1 This form should be completed by either the PERMIT APPLICANT or the I.A)CALAGENCY i !--! <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 />'FOP OF FORM: *MARK ONLY ONE MW <br />L 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 QrFacility name where the tank is installed. <br />1. TANK DFSCRUYIION- CAMPLETMIAIJ. TnWS- ]FUNKNOWN - 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. AT370789), <br />B. Indicate the name of the compapy 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 CONIEN117S <br />A. 1. If MOTOR VEHICLV 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 13 & D <br />B. Check the appropriate box. <br />C. Check the type of MOTOR VEI IICLE FUEL (if box I 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 Scivice <br />number), if box I is NOT checked in A. <br />III, TANK CONSTRUCTION - MARK ONE Tn3?M ONLY IN BOX t*, B, C & D <br />1. Check only one item in TYPE OF SYSTE-,M, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECnON. <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 I)EI'E(-nON system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK D9IV,(7IJb_N <br />1. Indicate the LEAK DCIFCTION system(s) used to comply with the nionitori4g-=quirenients for the tank. <br />V1. INFORMATION ON TANK PERMANENTI.,Y CLOSE0 IN PILACH VQAAiI <br />I.- ESTIMATED DATE IAST USED - MONTII/YFAR (January, 1988 or 01/88). <br />2. FS]IMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO'. <br />APPI.I(YWr MUST SIGN AND DATA 11111 FORM AS INDJCANFED. <br />INSTRUCTION FORT11H. IXWAL AGINCIES <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)719-2421. The facility number must be the same as shown in form 'A". 'D.e - <br />tank number may be assigned by the local agency-, however, this number must be numerical and cannot contain an alphabet. <br />the local agency prefers the State Board to assign the tank number, please leave it blank. <br />11T IST1111 RP—SPONSIBIIXI'Y OF 111E IDCAL AGENCY THAT INSPECIS 111E FAC1Irt7Y TO VERIFY '1111i <br />ACCURACY OF 111E. INPORMATION. 111F LOCAL AGENCY IS RESPONSIBLE FOR 1111:1 COMPIJNION OF TIIH; <br />4A)CAL AGIIN(Y USE ONLY* INFORMA11ON BOX AND FOR FORWARDING ONE IX)RM *IV AND ASSOCIATIO) <br />FORM '11'(S) TO 11111 1?011,OWING ADDRFISS. <br />STA"i OF CATIPORNIA <br />STNIM? WATER RESOURCES CON11kOL BOARD <br />C/O S.W.F-114 P.1 <br />DATA PRocussilmc, mvirm <br />P.O. BOX 527 <br />PARAMOUNT, CA 99M <br />