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„��r.-.�--••� ,,.�..��,� ,�.�.--- .... ?�<. ,. , .. ,Yl.�i.E":ifi'�',kr�° ' �,�1+,1-.S�i'�: _. s F-R _ ,� y�^ e <br /> IN91'RUC7nONS FOR COMPLETING FORM"B" <br /> GENERAL ll''+SFRIA.'i`iONS: <br /> 1. One FORM"B”shall be completed for each tank for all NEW PERMITS,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMiT APPI.1CANT or the I..00AL AGENCY UNDERGROUND TANK <br /> INSPEC10R. <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 IIEW <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-COMPLI:UI13 All.I TWS-IF UNKNOWN-SO SPIX:IFY <br /> A. Indicate owners tank 11) #-If there is a. tank number that is used by the owner to identify the tant (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.2.5,000 or 10,000 etc.). <br /> Q. TANK CON11WIS <br /> A. L If MOTOR VEHICLE FUEL,,check box I and complete items B&C. <br /> 2. If not MOTOR VEHICLE 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 C.A.S.#. (Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> M. TANK C ONS1'RUCn0N-MARK ONE ITEM:ONLY IN BOX A,13,C&I) <br /> 1. Check only one item in'I'YPE OF SYSI'EM,TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTHER,print in the space provided. <br /> TV. 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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> Vt. INFORMATION ON TANK PERMANENMY CLOSE)IN PLAC:I3 <br /> 1. ESTIMATED TATE LAST'USED-MON II/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMA'I'EI)QUANTITY of HAZARDOUS SUBS-FANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED WTL1-I INI R`l'MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUS1'SIGN AND DATE 1Ii13 FORM AS INDICATED. <br /> INSTRUCTION FOR TTIE 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 /> 1`171S THE;RESPONSIBILITY Y OF 1IIE 1..00'AL AGENCY THAT INSPEM, '11113 FACILII'Y TO VERIFY TILE <br /> ACCURACY OF 111E INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE C OMPLEIION OF 1IIE <br /> "LOCAL.AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOC IA113D <br /> FORM'B'(s)TO TITE FOLLOWING ADDRE.'S,S. <br /> STMT?OF CALIFORNIA <br /> SI'A1 E WATER RESOURCES CONTROL BOARD <br /> C/o S.W.E.E.P.& <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br /> 0 0 <br />