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INSIRUCIIONS FOR COMPLEIING,•FORM'B" <br /> GFNI3RAL INSTRUCTIONS: <br /> L - One FORM "B'shall be completed for each tank for all NEW PFRMjr CHANGES, RFMOVAI-%and/or any <br /> other TANK INFORMKIION CIIANGE- <br /> 2. This form should be completed by either the PF.'RMrr APP11CIVIZI'or the LO(AL AGENCY UNDERGROUND TANK <br /> INSPECI'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 TI1W <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-COMPLEll,ALI,rIMA4S-IF UNKNOWN-So SPECIFY <br /> A. Indicate owner-, 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.ACMETANKMFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the lank capacity in gallons (ex. 25,000 or 10,0W etc.). <br /> R. TANK CONIFNVS <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 the C.A.S.#. (Chemical Abstract Service <br /> number),if box I is NOT checked in A. <br /> 111. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX It,B,C&D <br /> 1, Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INIERIOR LINING and CORROSION PROITCnON. <br /> 2. If OTTIEK 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 DFI'117MON system(s)used to comply with the monitoring requirement for the piping, <br /> V. TANK LEAK DEFE(7111ON <br /> 1. Indicate the,I,FAK DUITCrION system(.,,) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMKIION ON TANK PERMANI.N11M(3,OSED IN PLACE <br /> 1. ES`nMA'IT.D DATE IASTUSFID-MONTH/YEAR(January, 1988 oroi/89). <br /> 2. ESTIMATED QUANFrI'Y of HAVARDOUS SUBSI'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATT I".? (hcck 'Ycs'or'NO'. <br /> APPLICANT MUST SIGN AND DX11,?11112,FORM AS INDRINIED, <br /> M.'I'RUCIION FOR 11111 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 Sta*e Board to assign the tank number,please leave it blank. <br /> fl'IS T11113 RESPONSIBILTI'Y OF"IE LOCAL AGENCY 171AFINSPIX.11'S TIIE FACILrFYTO VERIFY'llut <br /> ACCURACY OF'I1IE INFORMATION. THE LOCAL AGENCY IS Rr-;%'K)NSIBI.Jl FOR'11113 COMPtJTI1ON OF 11111 <br /> *LOCAL AGENCY USE.ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM W AND ASSOMIED <br /> FORM-B-(s)TO'ITIS FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE WATER.R07SOURCES CONIROL BOARD <br /> C/O&W.E.E.P.S, <br /> DATA PROCI-M'[NG CENIE.R. <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />