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INS11tUCI1ONS FOR COMPLETING FORM'B" GENERAL INSTRUCTIONS: 1. One FOIdM"T3"shall be completed for each tank for all NEW PERMI'T'S.,PEwrr CIIANGES, I VN4OVAIS anzl,/Or anv other TANK INFORMAI7ON CHANGE. 2. 'Phis form shjuld be completed by either the PERMrr APPIdC:ANi°or the;LOCAL AGENCY UNDERGROUND TANK INSPI:CrOR. 3. Please type or print clearly all requested in+ormation, 4. Use a hard point writing instrument,you sre making 3 copies. TY)P OI'FORM:'MARK ONLY ONE I'nm I. Mark an (X) in the box next to the item that lest describes the reason the form is being completed. 2. Indicate the MIA or facility name where the tank is installed. I. TANK DESCR1PT10N-COMPI13I13 AIl.ITEMS-IF UNKNOWN-SO SPWAJ Y" A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the lank ;ex.A13707i9). B. Indicate the name of the company that mim,,fact:urcd the tank(c V/111 TANK MFG.). C. Indicate the year the gunk was installed((x. 1987). D. Indicate the tank capacity in gallons(cx.25,0'00 or 10,000 etc.). U. "TANK CON71INI.5 A. 1. If MOTOR VEHICLES FUEL,check box 1 and complete iterns B& C. 2. If not MOTOR L 13HIC;LE FUEL,check the appropriate box in section A and complete items B 8z D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box i is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#.(Chemical Abstract Service number), if box 1 is NOT checked in.A. Ill. TANK CONSTRUCTION-MARK ONE 1`11iM ONLY IN BOX A,B,C&D 1. Check only one item in'TYPE OF SYSTP.,M,TANK MATERIAL, wrERIOR LINING and CORROSION PRO`EC'IION. 2. If OTHER,print in the space provided. TV. PIPING INFORMATION 1. Circle A if above ground;circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirement for the piping. V. TANK LEAK DLrrF.CI10N L Indicate the LEAK DF:TE CI'ION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PERMANENILY CIOSI9)IN PTAC E 1. ESJ IMAI'ED DATE LAST USE D-MON*1'II/'i EAR(January, 1988 or 01/88). 2. ESTIMATEI:)QUAN'IT:I'Y of RAVARDOUS SUBST'ANC'E remaining in the tank(in Gallons). 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes'or'NO% APPLIC ANI'MUST SIGN ANI)DAI'E11I11 FORM AS INDICA"1:191. INSTRUCTION FOR 111E LOCAL AGE.NCIFS 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 mpst 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. rT IS 111E RESPONSIBIIXIY OF TIJE LOCAL AGENCY TRAT INSPEC+ S THE FAC IIIIY TO VERIFY 111E ACCURACY OF TIM INFORMA7TON. 'I1IE LOCAI.AGENCY IS RESPONSIBI:I FOR'11IL COMPLI?110N OF 71113, "LOCAL AGI94CY USE ONLY'INI'ORMATION BOX AND FOR FORWARDING ONE FORM'A'AND ASSMIA'ILD FORM-W(s)TO T1IE F011.0WING ADDRESS. SPAT`:OF C:AIlFORNLA STA'II3 WA1`FR RESOURCES CONI'ROI.BOARD C/O S.W.E.I?P.S. DATA PROCI7SSING CEN11,�R P.O.BOX 527 PARAMOUNT,CA 9077.3