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INSTRUCTIONS FOR COMPL1r17NG FORM*B* <br /> GENERAI.IN5rRucn0NS- <br /> 1. One FORM "B" shall be completed for each tank for all NEW PERMITS,PERMIT CIVXNGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMII'APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> Z7 <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 OFFORNt."MAV,kONI..YONL�itli3iW , <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-DR/N or Facility name where the tank is installed. <br /> I. TANK DF-SCRJP`17ON-COMPII:'11!All.ITEMS-H?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(ex.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex.15,000 or 10,000 etc.).' <br /> H. TANK C!ONFENTS <br /> A. 1- If MO`I'0R VE111CLE FUEL,check box 1 and complete items B&C. <br /> 2. If not MOTOR VEHICLE FUEL,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 MEL(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 /> III. TANK CONSTRUCTION-MARK ONE n-EM ONLY IN BOX A,13,C&1) <br /> 1. Check only one item in TYPE 0FSYSTEM,TANK MA'I'ERIAL,INTERIOR LINING and CORROSION PROTECTION. <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. If UNKNOWN, circle:or if OTHER,print in space provided. <br /> 3. Indicate the LEAK DL�IEMON system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI3qV.Ct1ON <br /> 1. Indicate the LEAK DF' ( <br /> I'ECTION systems)used to comply with the monitoring requirements for the tank. <br /> VI. INIX)RMA'nON ON TANK PFRMANIWMY CIA)SIT13 IN PIACI! <br /> 1. ESTIMAAT.D DATE I.A51.I USED-MON],II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FlIJJ;D wriTi INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATII'17111E FORM&S INDICATED. <br /> INS-MUCIION FOR.111E 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 areedetermined and <br /> can be obtained by calling the State Board.(916)739-2421. 'IU facility number must be the same as shown in Cm "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 /> rr IS THE REspomswurry oFniii LOCAL AGENCY 11-INI'INSPE(TIN171F,FACIlffrY TO VE.RWY.'nil? <br /> ACCURACY OFTHE INFORMA7170N. 11JE.I.00AL AGENC`Y IS RESPONSIBLE FOR TTIE COMPLInION OFT11E <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND A,!;WC 3AIIII) <br /> FORM'B'(s)1`0 THE FOLLOWING ADDRESS. <br /> SrA*111!OF CAIIFORNIA <br /> SI'All-*WATIM RI: X)URC-F-S CONTROL BOARD <br /> C/o <br /> DATA PROCESSING CEAV11R. <br /> P.O.BOX 527 <br /> PARAMOUNT',CA WM <br />