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INSCRUCIZONS FOR COMPLETING FORM'B' <br /> GENERAL INSTRUCTIONS: . <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 /> y., 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENC4Y UNDERGROUND TANK <br /> INSPECTOR <br /> 3. Please type or print clearly-all requested information. <br /> s" 4. Use a hard point writing instrument,you are making 3 copies. <br /> mss': <br /> TOP OF FORM;'MARK ONLY ONE ITEM" <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 DESCRIPTION-COMPLETE All.ITE3MS-IF UNKNOWN-SO SPFX3FY <br /> A. Indicate owners tank I1)#-If there is a tank number th2t 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 the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons (ex.25,000 or 1.0,000 etc.). <br /> IL TANK CONTI:MS <br /> A. 1.If MOTOR VEHICLE FUEL, check box 1 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. Cheek the type of MOTOR VEIIICLE 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 Seivice <br /> number),if box 1 is 110T checked in.A. <br /> III. TANK CONSTRUCTION-MARK ONE 17119. 4 ONLY IN BOX A,B,C&1) <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PROT'EC'110N. <br /> 2. If 017JER,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 DE'TEC'TION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK I IAK DETECTION <br /> 1. Indicate the LEAK DT:TECTTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY(:[ABED IN PLACE <br /> 1. ESTIMATED DATE LAST USED-MONTIJ/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK MLLFD W171I1 INERT MATERIAL?Check'Yes'or'NO'. <br /> APPUCANT MUST SIGN AND DAT11111E FORM AS INDICATED. <br /> INSTRUCTION POR 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 /> IT IS TILT;RESPONSIBILITY OF TID3 LOCAL AGENCY TTIAT INSPECTS'11111 BACI]IIY'1'()VERIFY 111E1 <br /> ACCURACY OF THF INFORMA'I.1ON. TIIE LOC'AI.AGENCY IS RESPONSIBLE FOR TETE COMPLETION 011,T][111 <br /> 'LOCAL AGENCY USE:ONLY`INFORMATION BOX AND FOR FORWARDING ONE FORMA"AND ASS(X1XIED <br /> FORM•B'(s)TO TME FOLLOWING ADDRESS. <br /> STf4TE OF CALIFORNIA <br /> SLATE WATER RESOURCES CONTROL BOARD <br /> C/O S.W.EE.PS. <br /> DATA PROCESSING C EN1LR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9(YM <br />