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7 Ila .., - <br /> �, ;M; <br /> 5 nib <br /> INSTRUCTIONS FOR COMPLETING M'B' <br /> GENE INS77RU ONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PE?.RMT7:S,PERMIT CHANGES, REMOVALS and/or any <br /> other TANK INFO TION CHANGE. <br /> 2 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUNDTANK <br /> INSPF17170R. <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 I rm* <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 DFSCRIVIION-C OM.PLI?TEI ALL rI11MS-W UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank Il)# -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.ACIVIE 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 /> IL TANK(X) 'F.NI'S <br /> A. 1. If MOTOR VEHICLE FUEiL,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 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tat n4ehe C.A.S.#:(Chemical Abstract Service <br /> number),if box 1 is NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE 1`I1W ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OI"'SYSTEM,'TANK MATERIAL, INTERIOR LINING and CORROSION PROTECTION. <br /> 2. If OTEIEI2,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 OTIII,"R,print in space provided. <br /> 3. Indicate the LEAK DETECTION sy-stem(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DVI'FCI1ON <br /> 1. Indicate the LEAK DI TECI'ION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INE'C) ATION ON TANK PFAMANF,NI1,Y CLOSED IN PLACE <br /> 1. ESI°IMATED DATE LAST USF.:[)-MONTII/YFAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUAN'ITI'Y 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 DATE T1IR FORM AS ENDIC NI'ED. <br /> INSTRUCITON FOR 11IR 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 /> 11'IS TIIE?RESPONSIBHXIY OF THE LOCAL AGEN(Y THAT 1NSPF,CtS 111E FACILITY TO VERIFY THE <br /> ACCURACY OF TIIE INFORMATION. TILE LOCAL AGENCY IS RESPONSIBLE FOR TEES COMPLETION OF 31II; <br /> 'LOCAL AGENCY USE ONLY'INK)RMATION BOX AND FOR FORWARDING ONE FORM'A"AND ASSOCIATED <br /> TED <br /> - FORM'B'(s)'TO 111E FOIJ.OWING ADDRESS. <br /> STATE?OF CALIFORNIA <br /> SrAT1E WATER RESOURCES CONTROL BOARD <br /> C/O S.W.F E.P.S. <br /> DATA PROC,'TSSING C IWIMR <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90-M <br />