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v <br />INSTRUCTIONS FOR COMPLEn NG .FORM "LIN <br />GENERAL LNSTRUCTLONS <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVALS and/or any <br />other TANK INFORMATION CHANGE <br />2. This form should be completed by either the PERMIT APFUCANT or the LOCAL AGENCY UNDERGROUND TANK <br />NSPIC`1'OR. <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 IIIAe <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 />L TANK DFSCRWnON - COMPLETE ALL 1113MS - 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 />D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). <br />H. TANK CONTENTS <br />A. I. if MOTOR VEHICLE FUEL, check box 1 and complete items B & G <br />2. If not MOTOR VEHICLE 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 i 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 />ID. TANK CONST RUM- TON - 'MARK ONE ITEM ONLY IN BOX A, B, C & 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 />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 DETECTION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK LEAK DL�LCITON <br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VI. INFORMATION ON TANK PERMAN N1N T.Y CLOSED IN PLACE <br />I. ESTIMATED DATE LAST USED - MONTI-I/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). <br />3. WAS TANK FWLED WITH INERT MATERIAL? Check 'Yes' or 'NO'. <br />APPIJCANT MUST SIGN AND DATE THE FORM AS INDICATED. <br />U491 RUCT [ON FOR TTIN 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 conterin an alphabet. If <br />the local. agency prefers the State Board to assign the tank number, please leave it blank. <br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE <br />ACCURACY OF TILE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLLgION OI} TATE <br />"LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE DORM •A" AND ASSOCIATED <br />FORM -W(s) TO THE FOLLOWING ADDRESS. <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL, BOARD . <br />C/O &W.LE.P.S. <br />DATA PROCESSING CENTER <br />F.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />