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r <br /> INSTRUCTIONS FOR COMPLETING FORM"B" ' <br /> GENERAL INSTRUCTIONS_ <br /> 1. One FORM"B"shall be completed for each tank for all NEW PL>R, TS,PERMIT'CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PTS M APPLIC:'�NI'or the LO(:NL,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 ITF141" <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 DESCRIPTION-C OMPIZIT-4 All,ITEMS-117 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 th.cornpany that manufactured the tank(-x.ACME TANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,(00 or 10,000 ctc.). <br /> H. TANK CONIIWPS <br /> A. 1, If MOTOR VEHIC11:11 FUEL..,check box I and complete items B & C. <br /> 2. If.not MOTOR VEHICLE F^UF.,L,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 VEiHICI.,E 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 i is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSIMM,TANK MATERIAL,INTERIOR LINING and CORROSION PRO'IMCTION. <br /> 2. If OTITER,print in the space provided. <br /> 1V. 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 DE'I'EcTION syslem(s) used to comply with the monitoring requirement for the piping. <br /> V. PANIC LEAK DE'TF.C71ION <br /> L Indicate the LEAK DFIrEcTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANIWILY C II)SED IN PIACIE, <br /> 1. ESnMA7IT.D DA'I'S.;IAST USED-MONTII/YE:AR(January, 1988 ot•01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBS"TANCE3 remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INT wr ms.rERIAI.? Check 'Yes' car'NO'. <br /> APPLICANT MUST SIGN AND DA IL 111113 FORM AS INDICA IT?D. <br /> INSTRUCTION I?OR`E1IE IA)(:AI,AGLINCII S ' <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 Sta*e Board to assign the tank number,please leave it blank. <br /> IT IS nu.,RESPONSIBELII'Y OF IIIE LOCAL AGENCY TIIAI'INSPECPS TIIE FAGILIE'Y TO VERIFY'IIIE <br /> ACCURACY OF THE INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR IIiE C)MPI..IrIiON OF THE <br /> 'LOCAL AGENCY USB ONLY"INFORMAIION BOX AND In)R FORWARDING ONE FORM"A"AND ASSC)CIAI'E.D <br /> FORM"B"(s)TO 1111;FOI.IAWING ADDRESS. <br /> STAI13 OF CAIdFORNIA <br /> STA111 WATER RILSOURC.I3S CONTROI.BOARD <br /> C/O S.W.F?E:P.S:. <br /> DATA PRO(MSSING CI3NIT3R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9111723 <br />