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INSIRUCIIONS FOR COMPLETING ING TOR* <br /> GENERAL INSTRUCI"IONS: <br /> 1, One FORM"B"shall be completed for each tank for all NEW PF,RMITS,PERMTr C14ANG13A REMOVAIS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMr.r APPLICANT or the LOCAL,AGENCY UNDERGROUND TANK <br /> INSPEC'MR <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> I'OP OF FORM."MARK ONLY ONE ni'm <br /> L Mark an (X) in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicatc the DIA or Facility name where the tank is installed. <br /> I. TANK DESCRIPTION-CX)MPI.FM ALI,rTEMS-IF IJNKNOWN-, 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 MPG.). <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 /> 19. TANK CONTEMIS - <br /> A. 1. If MO'T'OR VEHICLE FUF..L,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 MO'T'OR VEHICLT3 FUF_L(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 I is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE 1`11M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, IN'T'ERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTITER,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'TIII3R,print in space provided. <br /> 3. Indicate the LEAK DE'II CI'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DFrrECIION <br /> 1. Indicate the LEAK DETF,('IIOiN system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMATION ON TANK PERMANFKI7 Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MON7II/YI_.AR(January, 1988 or 01/88). <br /> 2. ESTIMA'T'ED QUAN T11N of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WTI'TI INERT'MAI7✓RIAL? Check'Yes'or'NO'. <br /> APPLICANT MUSr SIGN AND Dxm]III?FORM AS INDICATED. <br /> IN,S'I'RUCIION FOR'nm LOCAL mmisicI84 <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 /> IT IS THE RFSPONSIBBZI'Y OF THE LOCAL AGENCY THAI'INSPF.CIS'IIEE FACILITY TO VERIFY IIID <br /> ACCURACY OF TIIE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 11113 C0MPI1,TnON OF THE <br /> *LOCAL AGENCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM"B"(s)'ro TIIE FOLLOWING ADDRESS. <br /> srXM'OF CALIFORNIA <br /> STArE WK17ER RESOURCES CONTROL BOARD <br /> C/O S.W.I?EP.S. <br /> IATA PROCESSING CFNII?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />