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INSTRUC`HONS FOR COMP1,1117NG FORM-B- <br /> Gtiwlzm.iNsTRucnoNs- <br /> 1. One FORINNI "B" shall be completed for each tank for all NEW PERMITS, Pi4,.RMrr CHANGES, REMOVAI-1;and./or any <br /> other TANK INFORMA`I1ON CIIANGE <br /> 2. 'I'his form should be completed by either the PERMIT APPLICANT'or the LOCAL AGENCY UNDERGROUND'I'ANK <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 YpEMI <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 DES CIVIION-COMPLInIl All,rrEMS-IF UNKNOWN-SO SPMIF1y <br /> A. Indicate owners tank ID #-If there is a tank number that is used by the owner to identify the tank(ex.A1370789). <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,15,000 or 10,W0 etc.). <br /> H. TANK CONIWfS, <br /> A. 1. If MOTOR VEHICLE FUEL,check box 1 and complete items B & C. <br /> 2. If not MOTOR VET11011' FUEL,check the appropriate box in section A and complete items B &1). <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 CA.S.#. (Chemical Abstract ScrNice <br /> number), if box 1 is NOT checked in A. <br /> III. TANK CONS'FRUC!I1ON-MARK ONE rtPM ONLY IN BOX.A,B,C&1) <br /> 1. Check only one item in'I'YPE OF SYSTEM,'TANK MATERIAL,INTERIOR I,ININ(3 and CORROSION PROTECTION. <br /> 2. If OTHER, print in the space provided. <br /> IV. PIPING,lNFoRmxnON <br /> 1. Circle A if above ground; circle U if underground,and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIJER,print in space provided. <br /> 3. Indicate the LEAK DEFECTION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DL MV71TON <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> V1. )NJ-X)RMA'nON ON`TANK PFRMANHVMY CLOSED IN PLAC'E <br /> I. ESTIMATED DATE, LAST'USED-MON]" /YEAR (January, 1988 or 01/88). <br /> 2. 1.1:15FINIATED QUANTITY of IIA7ARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 11 11 <br /> 3. WAS TANK FILLED W1111 INERT MA'IMRIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATI?111E FORM&S INDICATED. <br /> msmucnON FOR THE 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 State Board to assign the tank number,please leave it blank. <br /> rr IS mE RF-%w)N,,;i.Btjiw oFum LOCAL AGI.NCY"IKI'INSPEC'I'S,'111E FACJI.X17Y TO VERIFY <br /> ACCURACY OF'I7JE INFORM)VI1ON. ITIE LOCAL AGENCY IS RESPONSIBLE FOR nl[Ii COMP11NION OF'IIIE <br /> 'LOCAL AGENCY USE ONLY*INFORMA'17ON BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCINFED <br /> FORM'B'(s)1`0 11I13 FOLLOWING ADDRESS. <br /> SPATE 017 CALIFORNIA <br /> SDVIT'W)VIUR RESOURC'V-S COMIROL BOARD <br /> C/o <br /> DATA PROCESSTNG 0W1*ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90713 <br />