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INSTRUC11ONS FOR COMPIEIING,FORM*B" <br /> GENERAL INSTRUCTION& <br /> 1- One FORM "13'sball be completed for each tank for all NTV. PERM171N, PFRMIT CHANGES, REMOVAI.,S and/or any <br /> other'TANK INFORMATION CHANGE <br /> 1 '1 1 his form should be completed by either the PERMIT APPLICANT'or the LOCAI,AGI?NCY UNDI WG ROUND 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 nim <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 DESCRI1`170N-CX)MPLUIE ALI.ITIWS-IF 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.A1370789). <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 /> 11. TANK CONI'FNI'S <br /> A. 1. If MOTOR VEHICIA], FUEL,check box 1 and complete items B& C. <br /> 2. If not MOTOR VEHICLF 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 VEIIIICLE FUEL(if box 1. is checked in A). <br /> 1). 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 /> 111. TANK CONMRUC'nON-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,`TANK MA17ERIAL, INTERIOR LINING and CORROSION PRO'lT'.CTION. <br /> 2. If OTITER,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 DFFECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DfflrF(7110N <br /> 1. Indicate the LEAK DIrl'E.CTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMN11ON ONTANK P1iRMANI*!N17Y CIA)SED IN PLACE <br /> 1. ESTIMATED DA'I I E* LAST USED-MO"I/Yl.-!AR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAVARDOUS SUBSTANCE remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DXM7 71W,FORM AS INDICATED. <br /> INSTRUCTION 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#c Board to assign the tank number,please leave it blank. <br /> rr IS THE RESPONSIBILT17Y OF 1111?LOCAL AGENCY 71INFINSPEM 11111 FACTMTTO VERIFY 11111 <br /> ACCURACY OF'IIIE INFORMATION. 11111 LOCAL AGENCY IS RESPONSIBIlt FOR'11111 COMIPIITIION OF IIIE <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORMA"AND ASSOC INIED <br /> FORM-Ir(s)TO 11111 F0I.JLOWING ADDR11%. <br /> STA11i OF CALIFORNIA <br /> 91WIll?WATER RESOURCES CUMROL BOARD <br /> C/O S.W.E—F—P.S. <br /> DATA PR(X31SSING CENI'ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />