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INSTRUCI1ONS MR COMPIfftTNG FORM*Ir <br /> GENERAL INSIRUCIVRONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMIT'S,PERMIT CHANGES, REMOVAI.S and/or any <br /> other TANK INFORMATION CHANGE. <br /> 1 This form should be completed by either the PERMIT AFT11CAN17 or the IA)CAL AGENCY UNDERGROUND TANK <br /> INSTEC1'OR- <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> 'POP OF FORM:"MARK ONLY ONE rmw <br /> L 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 DESCRIPTION-COMPLETE ALL 1`119AS-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 tank (ex.AB70789). <br /> B. Indicate the name of The company that manufactured the tank(ex.ACME TANK MFG.). <br /> C. Indicate the year tl-,,. tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.2.5,000 or 10,000 etc.). <br /> 11. TANK CON IIINIS <br /> A. 1.If MOTOR VEHICLE FUEL,check box I and complete items B& C. <br /> 1 If not MOTOR VI*,111CLE 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 I 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 /> III. TANK(X)NS-1RUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&1) <br /> L Check only one item in TYPE OFSYSI'EM,TANK MATERIAI,11VIERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTIIER,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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DI--nX71-'ION <br /> 1. Indicate the LEAK DETECrION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMA11ON ON TANK PY-RMANEN11Y CIAXSED IN PIACE <br /> 1. ESTIMATED DATE LAST USED-MICNI'll/YEAR.(January, 1998 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBFIANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED ATIII INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUS'I'SIGN AND DATE17117,FORM AS INDICATED. <br /> INSTRUC711ON FORTIIE;II)CAL 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 RESPONSIBHX1rY OF 11111 IA)CAL AGENCY'1'1-1A`I'INSPHM, THE FAC111IT TO VERIFY TIIE <br /> ACCURACY OF`111EINFORMYV11ON. 17IL71.0(ALAGITNC'YISRF—SPONSIBLFFOR TTIE(X)MPLLrIIONOFTHE <br /> "LOCAL.AGENCY USE ONLY'INFORMATION BOX AND MR FORWARDING ONE FORM *A!AND ASSOCIATED <br /> FORM-B'(s)TO 111E FOU.OWING ADDRESS. <br /> STNIM OF CALIFORNIA <br /> SIATI11 WATER RESOURCES CONI'ROL BOARD <br /> C/o S.W-Fui-P.& <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />