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INSTRUCTIONS FOR COMPLIHING FORM'B' <br /> GENERAL INSl'RUC11ONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMI'M PERMIT CHANGES, RIFMOVALS 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 DORM:'MARK ONLY ONE I11%C <br /> 1. Mark an (X) in the box next to the item that best describes the reason the form.is'beipg completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> L TANK DPSCRIF17ON-COMPI.I'3'IU ALL LIEMS-W UNKNOWN-SO SPEiCIPY <br /> A. Indicate owners tank Ill # -If there is a tank number that is used by the owner to identify the tank(ex.A1170789). <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 /> Il. TANK CONTENTS <br /> A. L If MOTOR VF.HICLE FUEL,check box I 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 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 CONSTRUCTION-MARK ONE r1'EM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE,OF SYSTEM,TANK MATERIAL,INTERIOR LINING 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 OTIIER,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 DHrEC17ION <br /> 1. Indicate the LEAK DE-17EC1TON system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEN17 Y CLOSET)IN PIACE <br /> 1. ESTIMATED DATE LAST USED-MON` H/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of I-IALARI)OUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL?Check'Yes'or'NO', <br /> APPLICANT MUST SIGN AND DATE 111E FORM AS INDICATED. <br /> INSTRUCTION FOR T1IE 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. T'he facility number must be the same as shown in form "A". 1he <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 111E LOCAL.AGENCY MAT INSPECTS 111E FACILITY TO VERIFY TIM <br /> ACCURACY OP 11I13 INFORMATION. ITIE LOC.AI,AGENCY IS RESPONSIBLE FOR TIIE COMPLVIION OF THE <br /> RACAL 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 /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.E. -P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />