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INSI'RUC11ONS FOR COMPLE17ING FORM-B" <br /> GENERAL INSTRUCIIONS: <br /> 1. One FORM "B"shall be completed for caeh tank for all NEW PI RI rjs,PI3RMIr CHANGES, REMOVAI:S and/or any <br /> other TANK INFORMATION C IIANGE <br /> 2. This form should be completed by either the PERM1'r APPLICAN"r or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPI.M'OR. <br /> 3. Please type or print clearly all requested i tformation. <br /> 4. Use a hard point writing instrument,you are making 3 copies; <br /> TOP OF FORM:"MARK ONLY ONE I17:iM" <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 DBA or Facility name where the tank is installed. <br /> I. TANK DESCRIV['ION-COMPIZ113 ALL ITEMS-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.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(e;,. 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 1.0,000 ctc.). <br /> I1. TANK CONII:W15 <br /> A. 1.If MOTOR VEIIICLE FUEL,check box I and complete 'items B&C. <br /> 2. If not MOTOR VEHICLE FUI:I,,check the appropriate box in section A and complete items B &r D. <br /> B. Checkk 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 C ONSTRUCITON-MARK ONE..TT1:3M ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE,OF SYSTEM,TANK MATERIAL,INTERIOR LININrG and CORROSION PROTECIION. <br /> 2. If O'IIIER,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 DETECIION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK IEAK DHIW11ON <br /> 1. Indicate the LEAK DETECT"ION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMN ITON ON TANK PERMANENTLY C LASED IN PIAC13 <br /> 1. ESTIMATED DATE LAST USED-MONTIJ/YEAR(January, I'M or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED W FITI INERT MATERIAL?Check'Yes`or'NO'. <br /> APPLICANT MUST SIGN AND DNI73111E FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGI WCIES <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)739-1421. 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 Iocal agency prefers the State Board to assign the tank number,please leave it blank. <br /> rJ'IS TIIE RNSPONSIBI111.'Y OF THE LOCAL AGENCY T1INT INSPECTS TIIE FACILITY TO VERIF'Y'ITIE <br /> ACCURACY OF TIIE INFORMATION. 71IE IACAL.AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIIE <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND A.SSMIATI 1) <br /> FORM-W(s)TO TIIE FOLLOWING ADDRESS. <br /> SEKIIE OF CALIFORNIA <br /> SIA373 WATER RESOURCES CONTROL BOARD <br /> C/o SmIL E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUN I',CA WM <br />