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INS117RUCIIONS FOR COMPM, ING QM 'B' <br />GENERAL INSTRUCTIONS. <br />1. One FORM "B" shall be completed for each tank for all NEW PERMnN PERNff F CHANGF-S, RFIMOVAI-S and/or any <br />other TANK INFORMA71ION CHANGE. <br />1 This form should be completed by either the.PERM.Tr APPI1CAmr or the I.A)CAL AGENCY UNDERGROUND TANK <br />INSPECIIOR- <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 ONii nim <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 />I. TANK DF--,CRWIION - MMPI.FFP. ALL TITNS - IF UNKNOWN - SO SPECIFY <br />A. Indicate owners tank 11) # _ 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. ACMEIANK 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 />H. TANK CONTENTS <br />A. I. if MOTOR VEIIICLE FUEL, check box I and complete items B & C. <br />2. If not MOTOR Vf'.111CLE 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 I is NOT checked in A. <br />111. TANK CONSTRUCTION - MARK ONE rnM ONLY IN BOX A, B, C & D <br />L Check only one item in TYPE, OFSYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br />2. If OTIIET2, 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 OTIIER, print in space provided. <br />3. Indicate the LEAK DE`11C'I'ION sy-stem(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DITW)CIION <br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PtMMANFNII.Y CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED - MON17II/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FILLED WITH INERT' MATERIAL? Check 'Yes' or 'NO'. <br />APPLICANT MUST SIGN AND DATE THE FORM AS INDI(:NIM. <br />INS'MUC'11ON FOR111113 IA) AL AGENCIES <br />The state underground storage tank <br />nk 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 blank. <br />1171' IS THE RESPONSIBUXI'Y 017 THE LOCAL AGENCY 'nIX1' INSPMI 'S T11E FACILITY TO VERIFY 11111 <br />ACCURACY OFTIH! INFORMATION. ITIE UX:AL AGF.N(Y IS RESPONSIBIJ! MR IIIE COMP11-MON 01717111, <br />*LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE: FORM 'A' AND ASSOCINrED <br />FORM -Ir(s)'170, ITEE FOILOWING ADDRESS. <br />9171VtM OF CALIFORNIA <br />STATE WATER RESOUR(3N CONIROL BOARD <br />C/o smx-F-P.& <br />DATA PRO(-MSSING CFNIMR <br />P.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />