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INST RUCLIONS FOR COMPLFIING FORM'B" <br /> GENERAL INSTRUCITONS: <br /> 1. One I'ORM"B"shall be completed for each tank for all NEW PERMITS,PERMYI'CTIANGPS, REMOVAI S and/or any <br /> other TANK INFORMATION(MANGE. <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 clearlyall requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE IrIB " <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 /> 1. TANK DFSCRIPITON-COMPI UM ALL 111WS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID# -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 /> II. TANK CONTEN N <br /> A. 1, If MOTOR VEHICLI 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 VEHICI..E 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 ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PKO'1TCT10N. <br /> 2. If O'T'HER,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 DETECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DE`MC17ON <br /> 1. Indicate the LEAK DET'ECT'ION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CIASED IN PLACE <br /> 1. ESTIMATED DATE IASL'USED.MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of IIA%ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITIL INERT MATERIAL?Check'Yes'or'NO'. <br /> APPS K ANT MUST SIGN AND DATE 1.'HE FORM AS INDICATED. <br /> INSTRUCTION FOR TIIE LOCAL AI.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 fprm "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 RESPONSIIIE TTY OF TTIE LOCAL AGENCY 111AT INSPECTS THE FACILITY TO VERIFY TIIE <br /> ACCURACY OF TETE INFORMATION. THE UDCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION 017,77113 <br /> 'IXXAL AGF24CY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A'AND AS.SOCIA'{LD <br /> FORM"W(s)TO TAE FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONI'ROL BOARD <br /> C/O Sm-E.E.P.S. <br /> DATA PROCESSING CFNttiR <br /> P.O.BOX 527 <br /> PARAMOUNT,.CA 90723 <br />