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INSTRUCTIONS FOR COMPI TING FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PER14Rr5,PERhff CIIANGES, REMOVAIS 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 /> DaPECTOR. <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 r1TW <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 wherethe tank is installed. <br /> L. TANK DESCR moist-COMPL um ALL TT"As-IF UNKNOWN-s0 sPECII7Y <br /> A. Indicate owners tank Ill#-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(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 CONTENTS <br /> tl. 1.If MOTOR VEHICLE 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 ITEM ONLY IN BOX A,B,C&D <br /> I. 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 /> I. 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 DETECI"ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL. INFORMATION ON TANK PEWMANFNTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED•MONTH/YEAR(January,1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS 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 THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE 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. 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 IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FAC IIdTY TO VERWY THE <br /> ACCURACY OF TILE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR 11113 COMPLETION OF THE <br /> "LOCAL AGENCY USE ONLY'LNFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> FORM'B"(a)TO THB FOIdAWING ADDRESS. <br /> STATE OF CALIFORNIA. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/O SW.E.E.P S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />