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t ._,. .. 7-1 INSTRUCTIONS FOR COMP11?IING FORM"B" GENERAL INET RUC CONS: 1. One FORM "I3" shall be completed for each tank for all NEW PERMI C,,PI?RMIT CIIANGIxS, REMOVALS ami/or any other TANK INFORMATION CHANGE. 2. '1`his form should be completed by either the PERMTI'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 3. Please type or paint clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM'."MARK ONLY ONE TtEM"; ' 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 2. Indicate the IVM.or Facility name where the tank is installed. 1. TANK DFSCRIV110N-C OMPLUM?AId,r1.IMS-W UNKNOWN-SO SPI CIFY A. Indicate owners tank ID #-If there is a tank number that is used by the owner to identify the tank.(ex.A€370789). R Indicate the name of the company that manufactured the tank(ex.ACME,TANK MFG.). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.).` H. TANK C ONTEMIN A. L If MOTOR VEHICLE FUEL,check box'1 and complete items B&C. 2. If not MOTOR VEHICLE FUEL, check the appropriate box in section A and complete items B & 1.). B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUM.,(if box I is checked in A). D. Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number),if box 1 is NOT checked in A. III. TANK CONSIRRUCIION-MARK ONE n-EM ONLY IN BOX.A,B,C&D 1. Check only one item in'TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROT13C1'ION. 2. If OTHER,print in the space provided. IV. PIPING INFORMATION L Circle A if above ground; circle U if underground;and circle both if applicable. 2. If UNKNOWN, circle;or if OTHER,print in space provided. 3. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK DMVX'I10N 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. VL INFORMATION ON TANK PERMANIWI'I,Y CIOSWD IN PLACE 1. ESTIMATED DATE I..ASI'USED-MON1'€1/YEAR (January, 1.988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBS I'ANCE remaining in the tank(in Gallons). 3. WAS TANK FII.,LED WITH INERT MA77�R1.AI,'1 Check 'Yes'or'NO'. APPI1C:ANr MU917 SIGN AND DATE'nIE FORM A.S INDIC 11TED. IN.St RUCIION FOR 7I1E LCX AL AGENCIES The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2421. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain'an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. IT IS TEEE RI;SPONStBlITTY OF1111i IOCAL.AGENCY THAT'INSPECTS 11H!FACIIXtY TO VERIFY TIIE ACCURACY OF'ITIE INFORMNIION. TIIE LO(AL.AGENCY IS RESPONSIBLE TOR TIIE COMPT17I10N OF'I1IE 'LOCAL AGENCY USE ONLY"INFORMA TION BOX AND FOR FORWARDING ONE FORM'A''AND;ASSOC XVII) FORM'B'(s)TO 1.1t 1 FOLLOWING ADDRESS. STAW OF CALIFORNIA STA"TI:'s WA°TMR RESOURCES C OWROL BOARD C/O S.W.t?'1: PS. DATA PROC.I?SSING C:IWM1 R P.O.BOX 527 PARAMOUNI',CA 90723