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INS17RUCITONS FOR COMPLHITNG FORM"B" <br /> GENERAL IN'STRUCHONS- <br /> 1. One FORNI"B"shall be completed for each tank for all NEW PERMrl—,S, PERMIT CIIANGES, REMOVAI-S and/or anv <br /> other TANK INFORMATION CILANGE. <br /> 'I'his form should be completed by either the PERMIT'APPLICANT' `I <br /> or the LOCAL AGENCY UNDERGROUND <br /> INSPECTOR. <br /> Pleasetype oi-print clearly all requested information. <br /> )4. Use a hard point-writing instrument,you are making 3 copies. <br /> "F(W-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 /> 1. TANK DESCRIF11ON-COMPIZIM 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 /> 1). Indicate the tank capacity in gallons(ex.25,000 or 10,00 etc.). <br /> ]I. TANK CONTENTS <br /> A. 1. If MOTOR VF..HIC11],FUEL, check box 1 and complete items 13 & C. <br /> 2. If not MOTOR VEIIICLE- FUEL,check the appropriate box in section A and complete items B &1). <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 CA-S.#. (Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> HI. TANK CON'';IRUC`I7ON-MARK ONE ITEM ONLY IN BOX,A,13,C&1) <br /> 1. Check only one item in TYPE OFSYS`FEM,"TANK MATERIAL,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 OTHER.,print in space provided. <br /> 3. Indicate the LEAK DETECTIONsystemi(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETEC,11ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON"TANK PERMANEWtLY CU)SI0 IN PLACE <br /> I. ESTIMATED DATE LAST'USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. I_,STIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLI..D WITII INI.,.*KF MATERIAL? Check 'Yes'or'NO'. <br /> Appucwr muw SIGN AND DATE 111E FORM AS tNDICA11?D. <br /> INS'.MUCIION FOR 711E 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 Ward to assign the tank number,please leave it blank. <br /> IT IS 171E RESPONSIBILITY OF ITIE IOCAI.AGENCY IIIKI'INSPW-IN 171E FACII.X17Y 11)VERIFY IIIE <br /> ACCURACY OF 171E INFORMA11ON. 17111 IOCAL AGENCY IS RENPONSIBLE F1)R'nIE COMPLIT11ON OF IIIE <br /> "LOCAL AGENCY USE ONLY*INFORMN17ON BOX AND POR FORWARDING ONE FORMA"AND ASSOCIX17ED <br /> FORM'B'(s)TO-11111 MLLOWING ADDRESS. <br /> YrATH OF CAT IMRNIA <br /> STNIM WATER RESOURCnS COMIROI.BOARD <br /> C/o&W.EILP.S. <br /> DATA PROCF-SSING CENIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 900 <br />