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INFIRUC31ONS VOR COMPIHIING K)RM '13- GENERAL INS FRUC711ONS: 1. One FORM "B" shall be completed for ec.,-h tank for all NtFw ri.RMTIS, PERmn' (11ANGES., REMOVAIS andlor any. other 'TANK INFORMJVIION CHANGE 2, This form should be completed by either the PERMIT APPI.ICANr or the LOCAL AGENCY UND.ERGROUNDTANK IN,SPFk,'I'OR- 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument, you are making 3 copies. TOP OF 17ORM: "MARK ONLY ONE 171EM' 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. 'LANK DES(.'RIP`I1ON - WMI'll.r.1713 All, TI WS - It? UNKNOWN - SO SPECIFY A. Indicate owners, tank 11) # - If there is a tank number (hit is used by the owner to identify the tank (ex. AB70789). T B. Indicate the name of the company that manufactured The tank (ex. ACME TANK MFG.). C. Indicate the year the tank was installed (ex. 1987). I). Indicate the tank capacity in gallons (ex. 25,000 or 10,0M etc.), 11. TANK CONIWIN' A. 1. IfMOTOR VEHICLE FU11.11, check box I and complete items 11 & C. 2. If not MOTOR VljjlCI,j:7 RJEL, check the appropriate box in section A and complete items 13 & 1). B. Check the appropriate box. C. Check the type ofMO11 OR VEIIICIXI FUEL (if box I is checked in A). 1). Print ibe chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1. is NOTchecked in A. 111. TANK CONSTRUCTION - MARK ONE UIN ONLY IN BOX A, 13, C & 1) 1, Check only one item inTYPI OF SYSTEM. TANK MATERIAL, wru"RIOR LINING and CORROSION Pllar-Ecrm. 2. If OTHER, print in the space provided, IV. PIPING INFORMN11ON 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN, circle; or if OTIIER, print in space provided. 3. Indicate the LEAK DE"TECIJON system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DITHIGnoN 1. Indicate the LEAK DEAW-TION system(s) used to comply with the monitoring requirements for the tank, Vt. INFORMATION ON TANK PERMANE.IVILY ('71,031:11) IN PIAT, 1. ESTIMATED DA -11" IA51'USED - MONI-II/YEAR (January, 1988 or 01/88), 2. FSTIMATE,'D OUANHTY of HAZARDOUS SUBSTANCE rcma�ning in the tank (in (yallons). 3. WAS TANK FILLED WITH INHU'MATERIAL? Check 'Yes' or 'No'. APPticAmr MUST SIGN AND DKIE 111E FORM AS INDICATED. iNsrRu(711ON FOR 11111 I,OCAL ACWNCIEN The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421, The facility number most be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank- number, please leave it blank. ri, 1S '11113 RII.SPONSIBIIXIY OF "11111 LOCAL AGENCY711N.1' INSPR71S'llIE FACILRYTO VERII-N 1111E ACCURACY Oil 11111 INR.)RMNIION. 11112 LOCAL A(.jFN(,-f IS RE�SPONSIBITI FOR 11117 COMPLINION OF 11111 'LOCAL AGENCY USE1 ONIA* INFORMA11ON BOX AND FOR FORWARDING ONF FORM *A" AND AW)C1JVI13D MRM W(s)TO1111- FOLLOWING AI)DRF—SS. SrNI'F OF CAIJFORNIA STNIE WRIER Rl—;SOURCJ1S COMIROI. BOARD C/o &W.Euip.& DATA PROCIiSSING CIWllrR P.O. BOX 527 PARAMOUNI-, CA W72-3