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INSTRUCTIONS FOR COMPLETING FORM'B' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, R8MOVAI S and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This Iloorm should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSP <br /> R. <br /> 3. Please type or print clearly all requested information. <br /> �• C'�, 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM.'MARK ONLY ONE TITMI . <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 /> 1. TANK DESCRIPTION-COMPLETE All.ITEMS-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.A870789). <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.25,060 or 10,000 etc). <br /> B. TANK CONTENTS �. <br /> A. 1. If MOTOR VEHICLE 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 & 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 CA.S.$. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> BL TANK CONSTRUCTION-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 sysmm(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANI NILY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTH/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 INDICATED. <br /> INSTRUCTION FOR TIE 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 lank 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 /> IT IS TILE RESPONSB3am OF-n w LOCAL AGENCY THAT INSPECTS THE FACT1IlY TO VERIFY THE <br /> ACCURACY OF THE INFORMATION. 71111 LOCAL AGENCY IS RESPONSIBLE FOR THE COMPI.EIION OF THE <br /> RACAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC IA'1'ED <br /> FORM W(s)TO THE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E.EP s. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 , <br /> PARAMOUNT,CA 90723 <br />