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INSTRUCTIONS FOR COMPI.i?IING FORM 'B' <br />GENERAL INSl RUCTIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMZI' CHANGE?S, RFMOVAI S and/or any <br />other TANK INFORMATION (TIANGE. <br />2. This form should be completed by either the PERMIT APPLICANT or the I..00AI. AGENCY UNDERGROUND 'TANK <br />INSPECTOR. <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 ITEM' <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 />L TANK DESCRIPTION - COMPIJTM ALL ITEMS - IF UNKNOWN -SO SPFXWY <br />A. Indicate owners tank ID # - If there is a tank number that is used by the owner to identify the tank (ex. A1170789). <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 />MR, Il; TWI ►IMITIP <br />A. 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 />HL TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, INTERIOR LINING and CORROSION PRO'I1?CI10N. <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 DF 17ECI1ON system(s) used to comply with the monitoring requirement for the piping. <br />1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br />VL INFORMATION ON TANK PERMANENTLY CI,OSI33 IN PLACE <br />1. ESTIMATED DATE LASTUSED - MONITI/YFAR (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 />APPIJCANT MUST SIGN AND DATE 111E 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 RESPONS BAIT Y OF TAE LOCAL AGENCY THAT INSPECIS THE FACILITY TO VERIFY Tlil? <br />ACCURACY OF TIIE INFORMATION. TIIE LOCAL AGENCY IS RL;SPONSIBI.E FOR 173E COMPLETION OF THE <br />• ,OCAL AGENCY USE ONLY' INFORMATMON BOX AND FOR FORWARDING ONE FORM 'A' AND ASSOCIATED <br />FORM-W(s)1-0 THE FOLLOWING, ADDRE&S. <br />STATE OF CAIJFORNIA <br />STATE WATER RESOURCES CONTROI. BOARD <br />' <br />C/o S.W.E.E.P.S. <br />DATA PROCESSING cmNTER <br />P.O. BOX 527 <br />i'ARAMOUNT, CA. 90'723 <br />