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INSI'RUC110NS FOR COI PIPPING FORM"B" <br /> GENERAL IN.SrRUCLTONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PIsRMTI'S,PFRMrr 01ANClEs, REMOVAI.S and/or anv <br /> other TANK INFORMATION CHANGI? <br /> 2. This form should be completed by either the PERMIT APPLIOVT a'or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECIY)R. <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 I17I?11t" <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. PANIC DFSC FrIION-C OMPLIrl13 ALI,I'i'FdWS-III UNKNOWN-SC)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.ACMETANK 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 /> Il. TANK CONFFNI;s <br /> A. 1. If MOTOR VEHICLE, FUEL.,check box 1 and complete items 13 & C. <br /> 2.If,not MOTOR VEHICLE,'FUEL..,check the appropriate box in section A and complete items B& D. <br /> 13, Check the appropriate box. <br /> C. Check the type of MOTOR VEHICI..E FUEI,(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.S4, (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSIRUCIION-MARK ONE rI1?,11N ONLY IN BOX A,B,C;&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL, INFIERIOR LINING and CORROSION PROTE TION. <br /> 1 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 0"11IBR,print in space provided. <br /> 3. Indicate the LEAK DE—FECI"ION system(s)used to comply with the monitoring requirement for the piping. <br /> 'V. TANK LEAK DE1'F01ON <br /> 1. Indicate the LEAK DE'17ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INBYORMAIION ON'TANK PERMANIINILY CLOSED IN PLACE <br /> 1. EST'IMATI D DATE LAST USED-MONTI:I/YL:AR(January, 1988 of 01/88). <br /> 2 ES:C'IMATED QUANTCI'Y of HAVARDOUS SUBSI'ANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK:FILLED WITH INERT MA11 RIAL,? Check 'Yes' or'NO#. <br /> APPIJC ANT MUST SIGN AND DNMI 111E FORM AS INDI(W I13D. <br /> INN'I'RUCIION FOR 71113,IA)CAI.AG NC:IFS <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 numbefj 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 /> rr IS11113 RESPONSIBI111T OF TIIE LOCAL AGFN(,'Y 11IAI'INSP11C17S 1IIE FACILI71T TO VI?RIFY"'111E <br /> ACCURACY 017113E INFORMAIION. 'TI11?LOCAL.AGENCY IS RESPONSIBLE FOR'11113 COMPIdrI1ON OF 113E <br /> "IAC:AL AGENCY USE ONLY"INFORMAIION BOX AND FOR FORWARDING OM?FORM "A"AND ASSOCINIVI) <br /> FORM "B"(s)1`0'11111 1201.1.0WING ADDRIWS. <br /> SrA11?OF CALIFORNIA <br /> STA'IM WATER RHSX)URCIS C'ON'17ROI,BOARD <br /> C/O&W.BB PS. <br /> DATA PROC33SSING dWIVR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 900 <br /> r <br />