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INST'RUCIYONS FOR COMPIlg1NG FOR* • <br /> GENERAL IMM'RUC'TIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMrr CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CTIANGE. <br /> 2. This form should be completed by either the PERMPr APPLICANI'or the 1.00.AL 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 ONE TI'EM" <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 DESCRIVI'1ON-COMPI..F.'rE All,rl'FMS-114 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 manufactur=ed 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 CONTENT'S <br /> A. 1. If MOTOR VEHICLE FUPL,check box I and complete items B c&C. <br /> 2. If not MOTOR V141111CLE 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 tank-and-the C.A.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE r17EM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OIF`SYSTE..M,TART{MAIERIAI.., INTERIOR 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 O'ITLER,print in space provided. <br /> 3. Indicate the LEAK DE-,FECT ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETF.CRON <br /> 1. Indicate the 1J-.AK ISI✓1`ECRON system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANEM17LY CLOSED IN PLACE <br /> 1. ESTIMATED DAPI~I.,AST USED-MON-nl/YEAR(January, 1988 or 01/$8). <br /> 2. ESTIMATED QUANTITY of LIAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED wrnI INERT MA:FERIAI.? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND D)V I7?T1IE FORM AS INDIC NIED. <br /> INSTRUCTION FOR TILE LOCM.,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 agencyprefers the State Board to assign the tank number,please leave it blank. <br /> IT'IS THE RFSPONSIBHXI'Y OF THE LOCAL:AGENCY THAT'INSPECTS TTIE FACH TIY TO VERIFY'niE <br /> ACCURACY OF TIIE INFORMATION. 171E LOCAL AGF,NC'Y IS RESPONSIBLE FOR T1IE COMPIdTnON OF 1I1E <br /> *LOCAL AGENCY USE ONI Y"INFORMATION BOX AND FOR FORWARDING ONE FORM•A"AND AS,SOCIIATED <br /> DORM"B-(s)-M 111E POId.OWING ADDRESS. <br /> STAI'I OF CALIFORNIA <br /> SPATE WAII?R RESOURCES CONI'ROL BOARD <br /> C/O S.WX- P.S. <br /> DATA PROCESSING C1.NrI R <br /> P.O. BOX 527 <br /> PARAMOUNT,CA 90723 <br /> i <br />