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­777— <br /> INSTRUCTIONS FOR COMPIEnM A`Ir <br /> GENERAL INSTRUCTIO <br /> 1. One FORM"B",shall be completed for each tank for all NEW PERMTrN PERMIT CAANGFS, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the P1010 TT APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <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:-MARY.ONLY ONE P <br /> 1. Mark an(X)in the box next to the item that best desct bes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name where the tank is installed. <br /> I. TANK DFISCRIPTION-COWLALL n 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.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 /> 11. TANK CONT'LNI S <br /> A. 1. If MOTOR VEHICLE 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& 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-ahe C.A.S. . (Chemical Abstract Service <br /> number),if box 1.is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE Illi ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPEOFSYSTEM,TANK MATERIAL, INFERIOR LINING and CORROSION PROTECTION. <br /> 2. If.OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if aboveground;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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DHIMCIION <br /> 1. Indicate the LEAK DETECTION systcm(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORmTION ON TANK-PO MANEN LY CLOSED IN PLACE <br /> 1.-=.IMIMATED 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. SAS TANK.FILLED WITH INERT MATERIAL?Check'Yes'or'NO'. <br /> APPI.ICANr MUST SIGN AND'DATE THE FORM AS wmcArm. <br /> INSTRUCTION FOR'CIIE 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 localagency; 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 RESPONSIBRITY OF THE LOCAL.AGINCY TTIAf INSPECTS 11 FAC'ILIT'Y TO VERIFY TAF, <br /> ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLY?FOR TIME COMPLEITON OF IM <br /> `LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR.FORWARDING ONE FORM`A`AND ASSOCIATED <br /> FORM`W(s)°TO THE FOLLOWING ADDRESS. <br /> , I STA'1E OF CALIFORNIA <br /> STATE WATER RESOURC31S C ONIROL BOARD <br /> C/O S.W.RE.P.S. <br /> DATA PROCESSING CIWII'ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 91YT23 <br />