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INSTRUCTIONS FOR COMPLETING FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One 17ORM"B"shall be completed for each tank for all NI4W PERMITS,PERMIT CTIANGIIS, RPMOVAI S and/or any <br /> other TANK INFORMATION CTIANGE. <br /> 1 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> !. INSPECTOR <br /> 1 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 ONE II'I:tivl" <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 TANK DESC'RIPT'ION-COMPLETE ALL I11WS-W UNKNOWN-SO ST'ECTFY <br /> A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.AI370789). <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.25,000 or 10,000 etc.). <br /> II. TANK CONTENTS <br /> A. L If MOTOR VF.HICLI3 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 I 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 CONSTRUCTION-MARK ONE rl'F.M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INI'ERIOR LINING and CORROSION PRUITCI10N. <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 OTT-TER 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 DLrTEMON <br /> 1. Indicate the LEAK DE`TECT'ION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LASI'USED-MONI'1-I/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of I YARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED waii INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE T1LE FORM AS INDICATED. <br /> INSTRUCTION FOR TILE 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 /> IT IS THE RESPONSIBILITY OF THIS LOCAL.AGENCY 7I11AT INSPECIS'11113 FACTTM TO VERIFY TIIE <br /> ACCURACY OP 111E INFORMATION. 7I1IE LOCAI,AGENCY IS RESPONSIBLE FOR 11w-COMPLETION OF TILE <br /> "IA')CAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM-W(s)TO 111113 FOLLOWING ADDRESS. <br /> STATE OF CA11FORNIA <br /> STATE WATER RESOURCES C'ONIROL BOARD <br /> C/O Sm"-P.S. <br /> DATA PROCESSING C1?N113R <br /> i" P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />