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INSTRUCIIONS FOR COMPIJ_rHNG "B" <br /> GENERAL IN517RU ONS: <br /> 1. One DORM"B"shall be completed for each tank for all NEW PERMII$,PERMIT CHANGIA REMOVALS and/or any <br /> other TANK INFORMATION CIIANGF <br /> 2. This form should be completed by either the PERMIT APPLICANT or the LOCAL 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 Acapies. <br /> TOPOF FoRm"MARK ONLY ONE nuw <br /> 1. Mark an (X)in the box next to the item that best describes the reason the,f<orni is being completed. <br /> 2. Indicate the DSA or Facility name where the tank is installed. <br /> 1. TANK DESCRIPTION-C OM]P'L TM.ALL•T11iMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank ID #-If there is a tank number that is used by the ooV�tter_ fdeniify,the-[link(ex.AB70789). <br /> B. Indicate the name of the company that manufactured the tank(ex.ACME TANIK MFO.). <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 /> U. TANK C ON 17WI S <br /> A. 1. If MOTOR VEHICLE FUI>L,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. 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 tam and- lie-C.A.S4.(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> M. TANK CONSTRUCTION-MARK ONE T1`EM ONLY IN BOX A,B,C dt D <br /> 1. Check only one item in TYPE CSF SYSTEM,'LANK MA'T'ERIAL, INTERIOR LINING and CORROSION PROTECI'I )N. <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 0'11IER,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 DETF.CIION <br /> 1. Indicate the LEAK DETECITON system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANEMIIY CLOSET)IN PLACE <br /> 1. ESTIMATED DATE LAST USF.,D-MONTII/YEAR(January, 198f1 or 0188). <br /> 2. ESTIMA`IT.D QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WTI1I INERTMATERIAL?Check'Yes'or'NO' <br /> APPLICANT musr SIGN AND DATE TFIE FORM AS INDIC AIED. <br /> IN.S"TRUCTION FOR,niE LOCAL AGI_INc LS <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 /> r1'IS THE RESPONSIBIt1TT OF THE LOCAL AGFN( l f INSPECTS T1rL FAC IIM TO VERIFY 11THE <br /> ACCURACY OF TIIE INFORMATION. °IIIE LOCAL AGENCY IS RESPONSIBLE FOR 117111 COMPLETION OF LIE <br /> •LOCAL.AGENCY USE ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM*,W AND ASS IM <br /> FORM"B"(s)TO THE FOI.I.OWING ADD <br /> STATII OF CALIFORNIA <br /> STATE W.NIER ROSOURCHS CO OL BOARD <br /> C/O S.W.E.E.P S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90723 <br />