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0 0 <br />INS'IRUC17ONS POR COMPLEriNG FORM "B" <br />GENERAL INSTRU(TITONS:. <br />1. One FORINI "B" shall be completed for each tank for all N17W PERMITS, PERMIT CLIANGI?S, RIiMOVAI. S and/or any <br />other TANK INIIORMA71ION CHANGE. <br />2. This form should be completed by either the PERMII' APPLICANT' or the LOCAL AC.;<I NCY UNDERGROUND TANK <br />INSPIX:rOR <br />3. Please type or print clearly all requested information. <br />4. Use a hand point -writing instrument, you are making 3 copies. <br />TOP OF FORM: "MARK ONLY ONE ITEM" <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 (it I C41ity'name where the tank is installed. ...':.` <br />1. TANK DFSCRI '11ON-- C.OMPIZIM ALL rn.WS - IF UNKNOWN - SO SPIXIPY <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 I0,(X)0 etc,). . <br />H. TANK (X)NrENIN <br />A. I. If MOTOR VEIIICLE' 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 />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 1 is NOT checked in A. <br />III. TANK CONSTRU(NION - MARK ONE I113M ONLY IN BOX. A, B, C & I) <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING, and CORROSION PROT'ECT'ION, <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 I..EAK DL7FEC'TION system(s) used to comply with the monitoring requirement for the piping. <br />V. TANK 11I AK. DLrMX ITON <br />L Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VL IM-C)RMATION ON TANK PERMANIWII Y CLOSED IN PIACI? <br />1. ESTIMATED DATE LAST USED - MONIJI/YEAR (January, 1988 or 01/88). <br />2. ESTIMATED QUANTITY of HAZARDOUS SUB51'ANCE remaining in the tank (in Gallons). <br />3. WAS TANK PILLED WITH INEFtI' MA'IT.RIAI.,? Check 'Yes' or 'NO'. <br />APPLICANT MUST SIGN AND DATI? 11IE FORM AS INDICATED. <br />INSTRUCIION FOR TME LOCAL AGFNCI" <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)739-242.1. 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 />IT IS TILE RE.SPONSIBum OF Till? LOCAL Aw.NC.Y TI'IAT INSPECTS T11E FA(:11.XrY T() VE.RII'Y '1111; <br />ACCURACY OF171E INFORMATION. T1.111 LOCAL AGENCY IS RFSPONSIBIZ FOR TIIE COMPLHIION OF 171E <br />"LOCAL A6ENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND A.S,SOCIAIED <br />FORM "B"(s) TY) '1711.7 FOLL.OWINO ADDRFSS. <br />STA77b OF CALIFORNIA <br />STA'7:a tJ!'�1 T 1?R RI i,S()URCI?S ('()NI12C,)I, 3iC)AILi) . , <br />CIO kw.fu '.S. <br />DATA PROCESSING CIsNI73R <br />P.O. BOX 527 <br />PARAMOUNT, CA 90723 <br />