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INSTRUCTIONS FOR COMPI..ErI'i1SCi IAORM'B" ` <br /> GE,NJ MAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERM17.IS,PERMIT CIIANGIW'S, REMOVA1:5 and/or any <br /> other TANK INFORMATION CIIANGE <br /> 2. 'Ibis form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC`IY)R. <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 1'1171b1" <br /> L 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 DESC:RIPITON-C OMPLEIT3 ALL 171T?MS-III UNKNOWN-SO SPIIC'IErY <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 /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> 11. TANK C.ONI17MI;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& 1). <br /> 13. 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 /> ICI. 'TANK CONS'TRUC CON-MARK ONE TTE3M ONLY IN BOX A,B,C:&D <br /> 1. Check only one item in TYPE OF SYS'IMM,TANK MATERIAL, INTERIOR LINING; and CORROSION PRO`IT,C170N. <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'ITIER,print in space provided. <br /> 3. Indicate the LEAK DE'I'ECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LFAK DETF.(711ON <br /> 1. Indicate the LEAK DIi113CTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMNIION ON TANK PERMANEMILY C IA)SED IN PLACE <br /> L I:STIMA'IYD DATE:LAST USED-MONTII/YI.:AR(January, 1988 or 01/88). <br /> 2. 1±S511MATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FIL,LE;D Wini 1NI R'I'MATERIAL? Check 'Yes' or'NO'. <br /> APPLICANT MUST'SIGN AND DNI'E'111E FORM AS INDK IT?D. <br /> 1NS1RUCIIQN FOR 11113 LOCAL AGENCIPS <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 Stale Board to assign the tank number, please leave it blank. <br /> 1T'IS 11111 RFSPONSIBTT 1'LY OF 111E IAC.AL AGFINCY MAT'INSPI§CTS T"IIE FACTLrlT TO VEiRIFY"17111 <br /> ACCURACY 011111E INFORMX11ON. T1IE LOCAL AGI?NC:Y IS RESPONSIBLE FOR 111E3 COMPI.HIION OF 711E <br /> 'LOCAL AGRNCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC INIED <br /> FORM 'B'(s)TO'I1IE FOII..OWING ADDRI?SS. <br /> STAT1?OF CALIFORNIA <br /> STA17?WATER RI:SOURCrS CONTROI.BOARD <br /> C/o sm.I?E P.S. <br /> DATA PROC:I3SSING CMNITR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />