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0 <br />INSTRUC'IION,S FOR COMPIHIING PORM "B" <br />GENERAL INSI'RUC TIONS: <br />1. One FORM "B" shall be completed for each tank for all NEW PERMITS, PERMIT CHANGES, REMOVAI: S and/or any <br />other TANK INFORMATION CHANGE. <br />2. This form should be completed by either the PERMIT APPLIC AN ' 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 3 copies. <br />TOP Oil DORM: "MARK ONLY ONE M24" <br />L 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 DES MFrITON - C OMPLUI13 ALL, r1`EhIS - IF UNKNOWN - SO SPECIFY <br />A. Indicate owners tank ID tlt - 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 VEIIICIE 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 VEHICI.,I MEL (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 I is NOT checked in A. <br />III. TANK CONSTRUC:IION - MARK ONE ITEM ONLY IN BOX A, B, C & D <br />1. Check only one item in TYPE OF SYSTEM, TANK MATERIAL, IMFERIOR LINING and CORROSION PRO'I1 CTION. <br />2. If OTHER, print in the space provided. <br />IV. PIPING INFORMATION <br />L 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 DV- I'ECI1ON <br />1. Indicate the LEAK DEIMCI ION system(s) used to comply with the monitoring requirements for the tank. <br />V1. INFORMATION ON TANK PERMANIW17 Y C A)SED IN PLACE <br />1. ESTIMATED DAT:'E LAST USED - MONTH/YM.- R (January, 1988 or 01/88). <br />2. U'S:rIMATED QUANTrI'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 D/1IL TILE FORM AS INDICKI'ED. <br />MS -T RUCIION FOR 71111.. LOC:AI, AGENCIFS <br />r� <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 />II' IS 111E RESPONSIBILITY OF T13E LOCAL. AGENCY THAI' INSPECIS'11IE FACILITY TO VERIFY 11113 <br />ACCURACY OF'I71E INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR T11E COMPLI ION OF 11IE . <br />"LOCAL AGENCY USE ONLY" INFORMAIION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED <br />FORM "B"(s) TO 111E FOLLOWING ADDRESS. <br />STAB, OF CALIFORNIA <br />,STNIE WATER RESOURCES COMIROL BOARD <br />C/O S.W.E.E.P.S. <br />DATA PROCESSING CENTER <br />P.O. BOX 527 <br />PARAMOUNT, CA 9(rM <br />is 40 <br />