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INSTRUCIIONS FOR COMPLE'ITNG FORM'B* <br /> GENERAL INSTRUCHONS. <br /> 1. One FO RM'B"shall,be comple Led for each tank for all NEW PERMITS,,PE RMrl'CIIANGES, REMOVAI-S and/or anv <br /> Other TANK INFORMA11ON CSI G& <br /> 2 T rf`APPIJCAN`I*or the LOCAL AGENCY UNDERIGROUNDTANK <br /> Phis form should be completed by either the PFRM <br /> INSPECWR <br /> 3. Please type or print clearly all requested informatiop, <br /> 4, Use a hard point writing instrument,you ark;making;3 copi& <br /> TOP OF FOONLY 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 D13A or Facility name where the tank is installed. <br /> I. TANK DESCRIVIION-CMPLE173 ALI,11TEMS-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.AD70789). <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 /> H. TANK CONITNIS <br /> A. 1. If MOTOR VEIIICLF J'UEI,,check box 1 and complete items B&C. <br /> 2.It 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 I is NOT checked in A. <br /> III. TANK CONSMUC'nON-MARK ONE 1`11 JM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF'SYSITHM,TANK MATERIAL,INTERIOR LINING and CORROSION PROTECTION1. <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. It UNKNOWN.circle; or if OTHER,print in space provided. <br /> 3. Indicate the LEAK D11714"(77ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DUITI-711ON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMJVIION ON TANK PERM ANENII.Y CIX)SED IN PLACE <br /> L ESTIMATED DA'I'll LAST USEID-MONTYI/YEAR(January, 1988 or 01/88). <br /> 2. E-STIMATTID QUANTJ rl'Y of HAZARDOUS SUBSTANM, remaining in the tank(in Gallons)."- <br /> 3. WASTANK FILLED WITH INERT MA`17ERIAL? Check 'Yes'or'NO'. <br /> J <br /> APPLICAN'r MUST SIGN AND DMI11111F X)RM,'V%INDIQV17M. <br /> INS-IRUcnoN I�PR-11111 1,OCAI.AGENCIES, <br /> The state un ground storage tank identification number is composed of the two digit county number, the three digit jurisdiction <br /> number, Nsidigit 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 JS'ITIV RE-SPONSIBILTIT OF 111E LOCAL AGENCY'I'I-IAT INSPIR-715 171113 FA(AIJIT TO VERII-f'11111 <br /> ACCURACY OFnIP INFO TION. '111E.LOCAL AGENCY IS RESPONSIBLE FOR*nlE COMPLEITON OF*nIE <br /> 'LOCAL A(iENCY USE ONLY*INFORMNIION 130X AND MR FORWARDING ONE FORM*A*AND ASSOCIA717E3 <br /> VO RM, TO'11W FOIJOWING ADDRI._1W <br /> S-IWIV OF CALIFORNIA <br /> WYVII:,IR RINOURC"ES CO "ROI.BOARD <br /> C/o&W.ERlp.s. <br /> DXrA PROCI'SSING CEN'UM <br /> F-0,BOX 52,17 <br /> PAR_,,V%4OUN1',CA WM <br />