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INSI'RUCMONS MR COMP11117ING FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> L One FORM'13"shall be completed for each tank for all NEW PERMM,PERMrr C111ANGEN, REMOVAI—Sand/or mv <br /> other TANK INFORMA71ION CHANGE. <br /> 2. 'Phis form should be completed by either the PERMIT APPLICANT or the IA')CAL AGENCY UNDURGROUNT)TANK <br /> INSPECI'OR. <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 FORM*MARK ONLY ONE MM <br /> L 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 /> 1. TANK DESCRUMON-COMPLUM ALI,MIMS-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. A1,37078,, <br /> B. Indicate the name of the company that manufactured the tank(ex. ACMF'.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 /> IT. TANK CON11WIS <br /> A. 1. If MOTOR VEMCLE f.UI:71,,check box 1.and complete items B& C. <br /> 2. If not MOTOR VEHICIT IVEL,check the appropriate box in section A and complete items B& 1). <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 CA.S* (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE YnM ONLY IN BOX N 11,C&D <br /> 1. Check only one item in TYPE OF SYSIMM,TANK MNITIRIAL, INTERIOR LINING and CORROSION PROTECDON, <br /> 1 If 07TIER,print in the space provided. <br /> TV. PIPING IM70RMATION <br /> 1. Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if 01111311,print in space provided, <br /> 3. Indicate the LEAK DETEc-nONsystem(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK MAK DUIE(MON <br /> 1. Indicate the LEAK DFAE(71710N system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMMION ON TANK PERMANEMMY CMOSM)IN PLACE <br /> 1. E,5.nM/VI'ED DATE LAST USED-MON`.rfl/YF.-,AR(January, 1988. or 01/88). <br /> 2. FSHMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WFITT INERT MATERIAL?Check 'Yes'or'NO'. <br /> APPTICANI'MUST SIGN AND DAMMIE,FORM AS INDICAMD. <br /> INSTRUCTION FOR'nIF.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. 'I'lie county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board (916)739-2421. '"e,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 111F,RESPONSIBUXIT OF'ME LOCAL AGENCY 11IAT INSPEMIS 11111 FACIIrff 110 VERIFY 111E <br /> ACCURACY OF 11IE INFORMA17ON. ME IA)CAL AGENCY IS RESPONSIBLE FOR 11M COMPMION OF IIIFI <br /> *I)OCAI.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOCINI793 <br /> FORM-W(s)-1-0 11113 FOLIDWING ADDRESS. <br /> STNM OF CALIFORNIA <br /> ITM.111 <br /> ,WN171M RESOURCES CONIROL BOARD <br /> C/o S.W.um P.S. <br /> DMA PROCMSSING (,V.Nn?R <br /> P.O.BOX 527 <br /> PARAMOUNI',CA WM <br />