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WIR 111w- 1— 11; k. 7 <br /> INSIRU CONS FOR COMPIHITNG FORM*W <br /> GENERAL IN,10RUCUONS' <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMYI`S,PERMIT CHANGES, RF.MOVAIS and/or any <br /> other'TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPI.ICANT or the IX)CAI.AGENCY UNDERGROUND 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 rI13M' <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 /> L TANK DESCRIP'nON-COMPLffrE ALL 11711-414IS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 11.) #-If there is a tank number that is used by the owner to identify the tanL (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.2.5,000 or 10,000 etc.). <br /> 11. TANK CON11.?NIS <br /> A. 1. 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& 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 1 is NOT checked in A. <br /> M. TANK CON91'RUCnON-MARK ONE ITEM ONLY IN BOX A,K C&1) <br /> 1. Check only one item in'TYPE OF SYSTEM,TANK NINFERIAL. lN`FERIOR LINING and CORROSION PROTI:,'CI'ION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> L Circle A if above ground; circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if O'DIER,print in space provided. <br /> 3. Indicate the LEAK DETEC'1710N system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETE(7110N <br /> 1. Indicate the LEAK DF1,*ITt7FION system(s) used to comply with the monitoring-requirements for the tank. <br /> VI. INIIORMNIION ON TAMC PERMANENII.Y C1,A)SED IN PLACE <br /> 1. KSTFIMATED DATE I.A,;,r USED -MON-I-II/YLAR(January, 1988 or 01/88), <br /> 1 ESTIMATED QUA.N7n'I'Y of IJAZ.ARDOIJS SUBSTANCE remaining in the tank(in (iallons). <br /> 3. WAS TANK FILLED WITH [NJ-;Wf'MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND I)XIM11111 FORM AS INDI(WIT!D. <br /> INSTRUCTION FOR TIIE 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 /> rl'IS THE RESPONSIB111TY OF THE LOCAL.A(;ENCY 111JVI'INSPECIIS`[I IE FACIIrry TO VERITY IIIE <br /> ACCURACY 01711113.IN[FORMN110N. THE IXX:AL AGENCY IS RESPONSIBLE FOR TILE COMPLLqION 01711111 <br /> *LOCAL AGENCY USE ONLY'UVORMA11ON BOX AND MR FORWARDING ONE FORM W AND ASSOCIATED <br /> FORM'B'(s)TO THE FOLLOWING ADDRES!S. <br /> SrN]'F OF CALIFORNIA <br /> 91'XII!WATER RI&SOURCES CONIXOL BOARD <br /> C/o S.W.ILKP.& <br /> DATA PROCESSING(33NIEIR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9UM <br />