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VFW- <br /> INSTRUCTIONS FOR COMPLETING FORM"B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PI:;3Z14 l 4,PERMI'I:CHANGE:S, REMOVAE.S and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form.should be completed by either the PI 1'I"APPI GI N':I'or the LOC:AE.AGENCY UNDERGROUND TANK <br /> INSPECI'OR, <br /> 3. Please type or print clearly all requested information. <br /> d. Use a hard.point writing instrument,you are making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE rl1W <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 /> 1. 'TANK DESCRIPTION-COMPUn'H All.ITEMS-IF UNKNOWN-SO SFLVIFY <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 /> H. TANK CONIENTS <br /> A. 1. If MOTOR VEIIICLd,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. Cheek the appropriate box. <br /> C. Check the type of MOTOR VEHICLE,FUM..(if box.1. is checked in A), <br /> I). 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 /> IIL TANK CONSTRUCIION-MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1. Check only one item in TYPE OF SYSTEM,"TANK MATERIAL, WWI RIOR LINING and CORROSION 1'Rur CTION. <br /> 2. If OTIIER,print in the space provided. <br /> TV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground; and cirele 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 DL1713 I1ON <br /> 1. Indicate the LEAK DEiI:ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INIZORMA►IION ON TANK PI::RMANW11 Y C3,A)SED IN PLACE, <br /> 1. ESTIMA I D DATE[AST USEM -MONTII/YI::AR(January, 1988 or•01/88). <br /> 2. ESTIMATED QUANL'TTY of HA%ARDOUS SUBS"I'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INFR'T MA'L'L:ICIAL.? Check 'Yes'or'NO'. <br /> APPLICANT:MUST SIGN AND DATE 311H FORM AS INDHW110. <br /> INSTRUCII.ON FOR'.111I3 LOCAL AGLNC IPS <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 /> rI'IS'171E,RESPONSIBILITY OF 1711:1 LOCAL AGL?NCY'111NI'INSPI:,CIN'17111,FAC IL17TY TO VERIFY'ITIH <br /> ACCURACY OF WE INFORMAIION. TME LOCAL AGENCY IS RESPONSIBLE,FOR WE COMPI.JiIION OF 17113 <br /> RACAL.AGENCY USE,ONLY'INFORMAIION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM"B"(s)TO 111E FOI.IAWING ADDRI?SS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RFSOURCIN CONIROL BOARD <br /> i C/O SN.G'V11P.Sr <br /> ti <br /> DATA PROCESSING C EN`Jr .R <br /> P.O.BOX 527 <br /> PARAMOUNT',CA 9(1723 <br />