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INSFRUC 11ONS FOR t MP LIs"I`NG FORM"11' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PERMITS,PERMIT CHA REMOVALS and/or any <br /> other TANK INFORMATION C:TIANGE. <br /> 2. This form should be completed by either the PERMIT APPLICANT or the : ;TND TANK <br /> INSPECTOR.. <br /> 3. Please type or print clearly all requested information. <br /> t 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:"MARK ONLY ONE II'.M" <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 ID#-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.75,000 or 10,000 etc.). <br /> IL TANK CONTENTS <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. 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 NOT checked in A. <br /> III. TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX.A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,IiNTFERIOR LINING and CORROSION PROTECTION. <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 DETECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> 1. Indicate the LEAK DF,TECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY C.7.O.SED IN PLACE <br /> 1. ESTIMATED DATE LAST'USED-MONTII/YEAR(January,1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WII'II INERT MATERIAL?Check'Yes'or'NO'. <br /> APPLICANT MUST SIGN AND DATE TIIE FORM AS INDICATED. <br /> INSTRUCTION FOR,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)739-7421. 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 THE LOCAL AGENCY TIIAI"INSPECTS 11-IE FA(M l'CY TO VERIFY 11113 <br /> ACCURACY OF TIIE INFORMATION. TIIE LOCAL AGENCY IS RESPONSIBLE FOR TIM COMPLI?TION OF 111B <br /> "LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED <br /> FORM"B"(s)710 IIIE FOLLOWING ADDRI?SS. <br /> STATE OF CALIFORNIA <br /> STATE WATER RISOURCR9 CONTROL BOARD <br /> C/O&w.fZ-E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX S27 <br /> PARAMOUNT:,CA 90723 <br />