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INS1RU `IIONS FOR COMPLETING&-Ir <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGEA RRMOVAIS and/or any <br /> other'TANK INFORMATION CHANGE. <br /> 2. 'Phis form should be completed by either the PERMIT APPLICAM'or the LOCAL,AGENCY UNDERGROUNDTANK <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 ONE ITEM' <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 DESCRIPTION-COMPLETE ALL ITEMS-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,(00 or 10,000 etc.). <br /> 11. TANK 0ONTEN1-8 <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 FUEL(if box 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the,tar&and-the CA.S.#.(Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE rFEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,, INFERIOR 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 OTIIFR,print in space provided. <br /> 3. Indicate the LEAK DET'ECT'ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DEFECTION <br /> 1. Indicate the LEAK DEFECI10N system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANEI-411A CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTTI/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 DX-rF,'IIW-FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGEN(3ES <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 i 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 RESPONSEBIIXFY OF THE LOCAL AGENCY THAT INSPECTS THE FAC ILI17Y TO VERIFY 111E <br /> ACCURACY OF THE INFORMATION. IIIE LOCAL AGENCY IS RESPONSIBLE FOR IIIE COMPLETION OF IME <br /> *LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM-1r(s)TO UIE FOH.OWING ADDRESS. <br /> ,old STATE OF CALIFORNIA <br /> SPATE WATER RESOURCES CONTROL BOARD <br /> C/o S W.E.E.P.s. <br /> DATA PROCLISS71NG CFNFER <br /> P.O.BOX S27 <br /> PARAMOUNT,CA 90723 <br />