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IN' FIRUC`.nONS FOR COMPIZITNG FORM "B" <br />GFNERAL INSTRUCTIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMrr CIIANGES, REMOVAIS and/or any <br />other 'TANK INFORMN11ON CHANGE <br />2. This form should be conipletcd by either the PERMIT APPI.ICAmr or the LO AI, AGENC-Y UNDERGROUND TANK <br />INSPECTOR - <br />3. Please type or print clearly all requested information, <br />4. Use a hard point writing instrument, you are making 3 copies. <br />`1`OP 01? FORM: "MARK ONLY ONE rrEW <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 DESCRI1117ON - COMPLUFF All, 11 EMS - 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. ACMETANK 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#X) etc.). <br />11. TANK CON171VI'S, <br />A. L If MOTOR V1 ' 1,111CLE FUFIL, 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 />B. Check the appropriate box. <br />C. Check the type of MOTOR VEIIICLE FUEL (if box I is checked in A). <br />1). 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 />III. TANK CONSTRUCTION - MARK ONE nim ONLY IN PA)X A, B, C & 1) <br />I. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br />2. If OTIIF',It, print in the space provided. <br />IV. PIPING IN14)RMA71ON <br />1. Circle A if above ground; circle U if underground; and circle both if applicable. <br />2. If UNKNOWN, circle; or if OTIIEF, print in space provided. <br />3. Indicate the LEAK D171'ECT1ON system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK 1,EAK DM`EC11ON <br />1. Indicate the LEAK DFAECTION system(s) used to comply with the monitoring requirements for the tank. <br />VL INFORMATION ON TANK PERMANEMILY CIDSID IN PIAC!E <br />7 <br />1. EsTiMATED DATE I.AS'I'USED - MIONTI [/YEAR (January, 1,988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCF rema;ning in the tank (in Gallons). <br />3. WAS TANK FILLED WITI I lN1iKI'MAT[ -;RIAL? Check 'Yes' or 'NO'. <br />APP11CAN17 MUST SIGN AND DATE11111 FORM AS INDKWIFD. <br />INSFRUCIION FORT11111 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 State Board to assign the tank number, please leave it blank, <br />n, IS 11111 RE-SPONSIBI11IT OF TITE IOCAL AGINC'Y FACIIl`rYTO VERIFY'nIE <br />ACCURACY OF 11111 INFORMATION. "IE LOCAL AGENCY IS RIM)NSIBIli FOR TIIE COMPI,F11ON 011711E <br />"LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM 'A" AND ASSOC l[NI11D <br />FORM -1r(s) TO'ITIE FOLLOWING ADDRESS. <br />STATE OF CAIJFORNIA <br />SDVII.? WNI'ER RESOURCES CONI'ROL BOARD <br />C/o S.W.Ellps. <br />DATA PROCESSING CINI'ER <br />P.O. BOX 527 <br />PARAMOLINF, CA 90723 <br />9 46 <br />