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F ;I 7 <br /> �• d <br /> INSTRUCTIONS FOR COMFLI.M7 M'B" <br /> GENERAL INSTRUCTIONS <br /> E <br /> i 1. One FORM"B"shall be completed for each tank for all NEW I*L3AMTS,FLRIW T.( JA NGEA 1tEhtOVAIS and/or any <br /> other TANK INFORM ZION C11ANGF? <br /> E 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> E' INSPECTOR <br /> 3. Please type or print clearly all requested information. <br /> f 4. Use a hard point writing instrument,you are making-3 copies. <br /> G <br /> TOP OF FORM:'MARK'ONLY ONE riEM" <br /> 1. Mark an (X) in the box next to the item that best describes the icason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> i I. TANK DESCRIPTION-COMPLETE.ALL ITIWS-IF UNKNOWN-SO SPECIFY . <br /> A. Indicate owners tank Ill#-If there is a tank number that is used by the owiter`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). j <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> ,- <br /> It. TANK CONTI?.PTi'S <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 tank and the C..A.S.#.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> LII. TANK CONSIRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL.,, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTIIER,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 0111FR print in space provided. <br /> 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement,for the piping. <br /> V. TANK LEAK DETEAMON <br /> 1. Indicate the LEAK DEI'ECIION system(s) used to comply with the monitoring riqu-irements for the tank. <br /> VL INFORMATION ON TANK PERMANFWT Y CLOSET)IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTIIJYFAR(January, 1988 or 01/A8). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons), <br /> 3. WAS TANK FILLED WI`T'H INERT'MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE TFIE FORM AS INDICA'T'ED. w , <br /> INSTRUCTION FOR TIIE LOCAL AGI.940F_S <br /> Tfie'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 blink. <br /> IT. THE RFSPONSIBIII7'Y OF THE LOCAL AGFNYG'Y THAT INSPECTS 111E FACILITY 110 VLRIF7t THE <br /> ACL LACY OF TTIE INFORMATION. -111E LOCAL AGENCY IS RESPONSIBLE FOR THE COMPIP-HON OF THE <br /> 'LOCAL.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM"B"(s)TO TME FOLLOWING ADDRESS. <br /> STATE OF CAL.11?ORNIA <br /> STATE WATER RFSOURCHS CONTROL BOARD <br /> C/O&W.E.E.P S. <br /> DATA PROCESSING C E1`ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> �w <br /> , <br />