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INSTRUCTIONS FOR COMP111717ING A"Ii" <br /> GENERAL INS71'RUCI-IONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMRIPERwr CHANGES, RFMOVAIS and/or any <br /> other TANK INFOR?,"ITON CHANGE. <br /> 2 This form should be completed by either the PERMTI'APPLICANT'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPEC-I'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 num, <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 where the tank is installed. <br /> I. TANK DFSCRIVJ1ON-COMPLUFF,ALL TI`EMS-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(ex.ACMIETANX 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 /> H. TANK COM14NIN <br /> A. 1. If MOTOR VEHICLE F`UfL,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 VEIIICLE FUEL(if box I is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank-and4he,C-A.S.#;(Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK coNsimucnoN-MARK oNt,nim ONLY IN BOX A,B,C&D <br /> 1. Check only one item inTYPE OFSYSTEM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTTIER,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 il'01111,1R,print in space provided. <br /> 3. Indicate the LEAK DE1`C`I'I0N sy-,tem(s) used to comply with the monitoring requirement,for the piping. <br /> V. TANK LEAK DFrW)C7nON <br /> 1. Indicate the LEAK DL-I'E(.,'I'ION systern(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANFNIIY CLOSU-J)IN PLACE- <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1988 or 01/88). <br /> 2. ESTI.MXI'ED QUAN717ITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS LANK FILLED WH II INER71'MATERIAL? Check'Yes'or'NO'. <br /> APP11CANT MUST SIGN AND DA7133'ff IF,FORM AS INDICNIED. <br /> INSI7RUC!11ON FOR'n III 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 <br /> , prefers the State Board to assign the tank number,please leave it blank. <br /> rl'IS THE RF-SPONSIBIIXI'Y Of?WE LOCAL AGENCY THAI'114SPE M— '11113 FACH117Y TO VERIFY THE <br /> ACCURACY OF 11113 INFORMATION. '111E IXXW,AGENCY IS RESPONSIBLE FOR 11711F,COMPLIMON 017717111 <br /> 'LOCAL AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCIA117D <br /> FORM'B'(s)TO 71113 FOIJ.OWING ADDRESS. <br /> 9FA711!OF CALIFORNIA <br /> SrATE WNIlilk RESOURCES CON.I'ROL BOARD <br /> C/o Smy-E.P.s. <br /> DXrA PROCESSING CWt7ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA WM <br />