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INSTRUCTIONS FOR COMPLHIIN63 DORM"B" <br /> GEM3.RAL INSTRUCTIONS: <br /> L One FORM"B"shall be completed for each tank for all NEW PERMrIN,PERM-171`CIIANGEREMOVAI.-S and/or any <br /> other TANK INFORNM11ON CHANGE. <br /> 2. This form should be completed by either the PERMrFAPPLICANT or the LOCM.AGENCY UNDERGROUND TANK <br /> INSPE(70R. <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 ruor <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 1313.4 or 1:,'acility name where the tank is installed. <br /> 1. TANK DUS MIVIION-COMPLETE All.rl'EMS-1111 UNKNOWN-so SP1 FY <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 CON17,1VIS <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICIA4 FUEL,check the appropriate box in section A and complete items B & D. <br /> R Check the appropriate box. <br /> C. Check the type of MOTOR Vf',IIICLE 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 /> 111. TANK CONSIMUCHON-MARK ONE MiM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTE�CTION. <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 OTHER,print in space provided. <br /> 3. Indicate the LEAK DEFECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI3rr.F(711ON <br /> t Indicate the LPAK DSII'.CTIONsystem(s) used to comply with the monitoring requirements for the tank. <br /> VI. INF ORMNIION ON TANK PERMANIINI'LY 0A)SED IN PLACE <br /> 1. ESTIMNITD DA'L'E LAST USED -MONTII/Y 1IR(January, 1988 or 01/88). <br /> 2. ES'HMATED QUANTrry of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INEWI'MNITRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DA1E 111E FORM AS INDI(WFED. <br /> INS-MUCIION FOR 111E 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 showm 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 /> ITIS 111E RESPONSIIIILTI`Y 01111111 LOCAL AGENCY ITIAT INSPI.ICIS ITIE FACUXIN TO VERIFY ITIH <br /> ACCURACY OF'IIIE INFORMA11ON. '17111 LOCAL AGENCY IS RESPONSIBLE FOR 11133 COMPIM'11ON OF ITIE <br /> *LOCAL AGI?NCY USE ONLY'INFORMATION BOX AND FOR 14ORWARDING ONE FORM*A7 AND ASSO M, 31zD <br /> FORM -Ir(s)'IX)-1,1111 FOLLOWING ADDRESS. <br /> STATE OF(�A]11FORNIA <br /> STATE WATER RI K)URCES CONTIROL BOARD <br /> C/o smx-nps. <br /> DATA PROCESSING CHN'rF.R. <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />