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INSTRUCTIONS FOR COMPLi31ING FORM'Ir <br /> GENERAL INSIRUCIIONS. <br /> L One FORM "B" shall be completed for each tank for all NEW PERMTFS,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY 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 /> TOP OF FORM: "MARK ONLY ONEtrrEw. ;. . . . <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 .CGMPLLTTE All.I17MS-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.ACMF,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 /> IL TANK CONII?NIS <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 /> G 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 /> H1. TANK CONSTRUCIION-MARK ONE r11N ONLY IN BOX A,B,C&D <br /> 1. Check only one item in'IYPF.OF SYSTEM,TANK MA'T'ERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. if OTHER,print in the space provided. <br /> IV. PIPING IM70RMA11ON <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN, circle; or if OUTER,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 DI3q`EC"IION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENIZY CLOSED IN PLACE <br /> I. E,,,mmATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN'TIT'Y of HA7ARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WI'11E INERT MATERIAL?Check 'Yes' or'NO'. <br /> APPI1CANr MUST SIGN AND DA113117E FORM AS INDICATED. <br /> INSI'RUCION FOR'IIIB DDCAL AGENCIF_S <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 lank number, please leave it blank. <br /> rl'IS TIII?RESPONSIBILITY OF 7IIE LOCAL AGENCY THAI' NSPI-IS 771E FA(1IITY TO VERIFY THE <br /> ACCURACY OF 7IIE INFORMATION. THE LOCAL AGENCY IS RESPONSWUH FORTHE COMPLEr LION OF 7116 <br /> "LOCAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM 'W(s)'TO 1111?FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STAB WATER RISSOURCES CONTROL.BOARD <br /> C/O S.W.F_EP.S. <br /> DATA PROCESSING CENIER <br /> P.O. BOX 527 <br /> PARAMOUNT, G.90713 <br />