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�,-rs:K.�::yvr.,."'.� ..�.,- � ,: ,., ,. -.w -,',4,-„rr^•-max,:., ,: ,.,y a. ..,a.v. .+:: �, �s:k. . :�i. yt�,. � k<�'"x. <br /> INSTRUCTIONS FOR C OMPLEIING FORM B' <br /> GENERAL INSTRUCTIONS: . <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CIIANGES, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> 0 INSPECTOR <br /> e <br /> s, 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 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 ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank Ill#-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 the tank was installed(ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,000 etc.). <br /> H. TANK CONTENTS <br /> A. 1.If MOTOR VEHICLE FUEL,check box 1 and complete items B& C. <br /> 2.If not MOTOR VF.,IIICLE 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 T'1OT checked in.A. <br /> III. TANK CONSTRUCTION-MARK ONE rnow ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,INTERIOR LINING and CORROSION PRO"TEC7110N. <br /> 2. If OTHER 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`FF,CIION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK IEAK DLrMCIION <br /> 1. Indicate the LEAK DETECIION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANENTLY(MOSFD IN PLACE <br /> 1. ESTIMA'T'ED DATE IAST USED- MON'lj/YEAR(January, 1988 or 01/88).., <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WITH INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATIVIIIE FORM AS INDICATED. <br /> INSTRUCTION FOR TLIE 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 TETE RESPONSIBILITY OF 11111 LOCAL AGENCY 1IIAT INSPECTS 311E FACS iTY TO VERIFY TELL; <br /> ACCURACY OF THE INFORMATION. T1IE L..00AL AGENCY IS RESPONSIBLE FOR TIIE CoMPI. nON OF TlIE <br /> "LOCAL,AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSO C'IA'I10 <br /> FORM'B"(s)TO TILE FOLI OWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STATE,WATFR RESOURCES CONTROL BOARD <br /> C/O S.W m—PS. <br /> DATA PROCESSING CIt MR <br /> P.O.BOX 527 <br /> PARAMOUNT•,CA 907x1 <br />