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o <br /> INSI'RUCIIONS FOR COMPLEr11N PPORM'B' <br /> GI NERAL INSL'RUCTIONS: i <br /> L One FORM"B"shall be completed for each tank for all NEW PERMrI.'N PERMIT'CLIAN€AES, REMOVAE:S and/or any <br /> other TANK 1NFORMN110N CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI1CANI'or the LOCAL,AGENCY UNDERGROUND TANK <br /> INSPECCOEL <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 rI7EM' <br /> I. 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 DESCRI1''17QN-€OMPI.E TE ALL HT-IMS-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 Oame 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. 25,000 or 10,000 btc.),., <br /> H. TANK CONIIWFS <br /> A. 1. If MOTOR VEHICLE,FUM.,,check box 1 and complete items B&C. <br /> 2. if not MOTOR VEHICI..E FUEL..,check the appropriate box in section A and complete items B fir L). <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLI 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 Abstra/service <br /> number), if box 1 is NO'r checked in A. <br /> 111. TANK CONII; R.UCIION-MARK ONE ITEM ONLY IN BOX A,B,C dt D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER, print In the space provided. <br /> 1V. PIPING INFORMATION <br /> L Circle A if above ground; circle U if underground; and circle both if appli6l)le. <br /> 2. If UNKNOWN, circle; or if OTHER,print,ie space provided. <br /> 3. Indicate the LEAK DE-n_,CTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DLTL7?.C110N <br /> 1: Indicate the LEAK DE17F. N system(s) used to comply'with the monitoring requirements for the tank. <br /> VI. INFORMA310N ON TANK PERMANE3NILY CLOSED IN PLACE <br /> L ESUMA'TE:D DATE LAST USED-MONTH/YEAR(January, 1.988 or el/88). <br /> 2. ESTIMATED QUANITI'Y of HA%ARDOUS SUBSTANCE remaining'in the tank(in Gallons). <br /> 3. WAS TANr, FILLED WITH INERT MNITRIAI.? Check 'Yes'or'NO'.-" <br /> APPLICANT MUST SIGN AND DATE?111E FORM AS INDICATED. <br /> INSTRUCTION FOR 11M 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 Sta*e Board to assign the tank number,please leave it blank. <br /> r . <br /> II'IS"71I1?RESPONSIBUX1.7Y OF 11II:I LOCAL.AGENCY THAT INSPF.CIS 11IE FACILITY'1'O VERIFY 1111? <br /> ACCURACY OF'111E INFORMA11ON. TIIE?EOCAI.AGENCY IS RESPONSIBLE FOR 111E COMP11 I10N OF 1,11E <br /> 'LOCAL AGENCY USE ONLY'INFORMNIION BOX AND FOR FORWARDING ONE FORM'A'AND AS,SOCAIM <br /> FORM'B'(s)TO-11111 FOEI,OWING ADDRFSS. ' <br /> SrA11?OF CALIFORNIA <br /> STMT!WA1ER RESOURCES C'ONI'ROI,BOARD <br /> C/O S.W.1?E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 90713 <br /> i_ <br />