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INSTRUCTIONS FOR COMPLLrI'IiVCi DORM 'Ii" 0 <br />GENERAL INSTRUCTIONS: <br />1.. One FORM "B" shall be completed for each tank for all NEW PERMII:S, PF,RMIT CHANGES, REMOVAIS and/or any <br />other TANK INFORMATION CHANGE. <br />2, 'Ibis form should be completed by either the PERMIT APPLICANT' or the LOCAL.. AGENCY UNDERGROUND "TANK <br />INSPECI'OIL <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 F()RM: "MARK ONLY ONE 1'nW* <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 />1. 'TANK DESCWr11ON - C OMPI El'I? ALL ITEWS - 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. 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 installed (ex. 1987). <br />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />IT. TANK CONFENIN <br />A. 1. If M01:'OR VEHICLE FUEL.., check box 1 and complete items I3 &s C. <br />2. If not MOTOR VEIIICLE FUEL, check the appropriate box in section A and complete items B d't D. <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 />111. 'TANK CONS17RUC170N - MARK ONE ITEM ONLY IN BOX A, B, C& D <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INIERIOR 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 LAK DETECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. 'TANK LEAK DETEC:LION <br />1. Indicate the LEAK DUITX717ION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMN11ON ON TANK PERMAMNILY CEASED IN PIAC3:3 <br />1. ESTIMAT14.D DA7:'E LAST USED - MONTII/YEAR (January, 1.988 or 01/88). <br />2. ESTIMATED QUANTITY of 1IA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes' or 'NO'. <br />APPLICANT MUST SIGN AND DA113 THE FORM AS INDICATED. <br />INSTRUC11ON FOR 11111; 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 />�\ II' IS T1113 RESPONSIBILITY OF 11111 LOCAL AGENCY THAT INSPECI:S 1ILE FAC'ILIIT TO VERIFY TI -11r <br />ACCURACY OF'11IE INFORMATION. THE LOCAL. AGENCY IS RESPONSIBLE FOR 311E COMPII:IION OF IIIE <br />\ "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED <br />FORM 'B'(s) TO 711113 FOI.IA)WING ADDRESS. <br />STA'I7:3 OF CALIFORNIA <br />.STt1Tia WATER RESOURCES C'ONTROI. BOARD <br />C/O S.W.E.E.P.S. <br />DATA PROCESSING C:ENII3R <br />P.O. BOX 527 <br />PARAMOUNT', CA 9072.3 <br />