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INSTRUCTIONS FOR COMPIHITNG FORM"B" <br /> GENERAL INS' 'R Vit:i IONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMII`CIIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CIiANGIL <br /> 2. This form should be completed by either the PERMIT APPI.IC ANT 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 /> 'I'OP OF FORM: "MARK ONLY ONI?nEw <br /> L 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 /> L TANK DESCRIPTION-C OMPI.F.M.ALL r1104S-IF UNKNOWN-SO SPMFY <br /> A. Indicate owners tank ID # -If there is a.tank number that is used by the owner to identify the tanL (ex.A1370789). <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.2.5,000 or 10,000 etc.). <br /> 11. TANK CON11WIN <br /> A. 1.If MO'T'OR VEHICLE FUEL,check box "i and complete items B&C. <br /> 2.If not MOTOR.VI3111CLE 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 C ONSi'RUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&I) <br /> 1. Check only one item in'TYPE OF SYS'T`EM,TANK MATERIAL, INTERIOR I.,INING and CORROSION PROTEC`I'ION. <br /> 2. If OTHER,print in the space provided. <br /> TV. 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 system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK D1;IIX71ION <br /> 1. Indicate the L,FAK DETECTION systent(s) used to comply with the monitoring requirements for the tank. <br /> Vi. INFORMAIION ON TANK PERMA.NENII.Y C A SI:7)IN PLACE <br /> 1. ESTIMATED DATE I.AS"1'USED-MONIII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMA'IT0 QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTIII INER i'MATERIAE? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DAIM THE FORM AS INDICA'T'ED. <br /> INSTRUCTION FOR THE LOCAL.AGINCIIS <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". <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 /> rI'LS THE RESPONSIBILITY 011'11111 LOCAL AGENCY THAT INSPEm,'mI FACILCTY TO VERIFY THE <br /> ACCURACY OF 11113 INFORMATION. T1IE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIIH <br /> •LOC,AI-AGI:NCY USE ONLY*INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIA'1'13D <br /> FORM"B"(s)TO TIIE FOLLOWING,ADDRESS. <br /> STAT'?OF CALIFORNIA <br /> STXI'L WATER RESOURCES CONTROL BOARD <br /> C/O S.W.—u—P,S. <br /> DATA PROCESSINSING CI:WTILR <br /> P.O.BOX 527 <br /> PARAMOUNI7,CA WM <br />