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INSTRUCTIONS FOR COMPIJTiING FORM*B* <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT'CHANGFS, REMOVALS and/or any <br /> other TANK INFORMATION CHANGE: <br /> 2. This form should be completed by either the PERMIT APPLICANT or the IACAL 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 OF FORM:'MARK ONLY ONE P11W- <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 /> 1. TANK DESCRIPTION-COMPL.E rE All,ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. Indicate owners tank 1D#- 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 CONII7NIN <br /> A. 1. If MOTOR VEHICLE FUEL,,check box I and complete items B R C. <br /> 2. If not MOTOR VF1lICIII;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 FUIEL(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 CON917RUCTION-MARK ONE ITEM ONLY IN BOX A,13,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'I'ANK MATERIAL,INTERIOR LINING and CORROSION PRO'1TC110N. <br /> 2. If OTHER,print in the space provided. <br /> I.V. 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 D1 TEC`I10N system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK I..FAK DITIECI`ION <br /> 1. Indicate the LEAK DETECTION system(s)used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANFN11.Y CLOSED IN PLACE <br /> I. ESTIMATED DATE L.ASI USF3D-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK 1 LLED WI1.1-1 INERT MATERIAL? Check 'Yes'or'NO'. <br /> APPIJCANT MUST SIGN AND DATE TIM 17ORM AS INDIC:A11.0. <br /> INSTRUCTION FOR I1IE IXWAL,AGENCIES <br /> 'rhe 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 /> 1T IS TILE RISPONSIBrim OF i7m LOCAL AGENCY 11IAr INSP1cIs Tim FACILITY TO VERIFY'1T1E <br /> ACCURACY OF TILE INFORMATION. TILE,LOCAL AGENCY IS RESPONSIBIJ FOR ITIS COMPI.EI'ION 011113E <br /> 'LOCAL.AGENCY USI:ONLY'INFORMATION BOX AND FOR FORWARDING ONE FORM-A-AND ASSOCIAIVD <br /> FORM-B-(s)TO TELE FOIJ.OWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STA17?WATER RESOURCES CONTROL BOARD <br /> C/O S.W.Im P.S. <br /> DATA PROCESSING CF.N1`ER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA W123 <br />