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INSI:'RUCTIONS FOR COMPLITIING FORM*W <br /> GENERAL INSTRIA 31ONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMIT'S,PERMIT C.`EIANGILS, R.EMOVAIS and/or any <br /> other TANK INFORMATION CHANGI? <br /> 2. This form should be completed by either the PI:3RMIT APPLICANT or the IA)C'AI.,AGFNCY UNDERGROUND TANK <br /> INSP F.C101L <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> '11OP OF FORM:"MARK ONLY ONE ITEM' <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 /> L 'LANK DESCRIPTION-C OMPIRM ALL,rITIMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank II) #-If there is a.tank number that is used by the owner to identify the rank (ex.A1370789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANK MFC:r.), <br /> C. Indicate the year tfiQ tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.). <br /> 1I. TANK CON'11WIS <br /> A. L If MOTOR VEHICLE FURL,check box I and complete items B & C. <br /> 2.If not MOTOR VI:IIICLE 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 C.A.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK C ONSIRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MNI'ERIAL, INTERIOR I.,INING 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 DETECT`ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DifrEC TION <br /> 1. Indicate the LEAK DETECTION systems) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA'T'ION ON TANK PERMANENTLY CLOSED IN PLAC13 <br /> 1. ESTIMATED DATE LAST USED-MONI1l/YEAR(January, 1984 or 01/88). <br /> 2. ESTIMATED QUANTITY of I1N/ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WI'T'H INEIC C MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR TI IE 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 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 tank number,please leave it blank. <br /> r1'IS TTIE3 RE?SPONSIBHX17Y OF TE113 LOCAL AGENCY THAT IN3Pl.CTS'IITT3 FACILITY TO VI RIFY TIII3 <br /> ACCURACY OF'111E INFORMAITON. TIII?LOCAL AGENCY IS RESSPONSIBLF FOR THE COMPLETION OF THE <br /> 'LOCAL AGENCY USE ONLY INFORMN11ON BOX AND FOR FORWARDING ONE FORM'A'AND ASSOCWIED <br /> FORM'B'(s)TO THE FOLLOWING ADDRESS. <br /> STAT:.OF CALIFORNIA <br /> ST:NIE WA'T'ER RESOURCES CON17ROL BOARD <br /> C/o S.W-E?R P.S.. <br /> DATA PROCESSING C ENIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />