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INSTRUCIIONS FOR COMPLUI1NG FORM*B* <br /> GENERA1.IN:i TRUCTIONS <br /> L One FORM"B"shall be completed for each tank for all NEW PERM17IN,PERMIT CHANGES, REMOVAL:S and/car any <br /> other TANK INFORMATION CHANGE. <br /> 2. This form should be completed by either the PERMIT APPLIC.ANI'or the LOCAL,AGENCY UNDERGROUND TANK <br /> INSPECI.'OR <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 I111bI" <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 DFSC:RIPITON—C OMPIZFE ALI,rIT?MS-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.25,000 or 10,000 etc.). <br /> 11. TANK CONI'F.NIN <br /> A. 1. If MOTOR VEIIICI.;E FUEL,check box 1 and complete items I3&C. <br /> 2. If not MOTOR VEHICLE' FUEL..,check the appropriate box in section A and complete items B bt D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLE FUEL,(if box 1 is checked in A). <br /> 1). 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 C.`ON.STRUCIION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL, IM ERIOR LINING and CORROSION PRO'TI:C170N. <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 DT;1'ECI'ION system(s) used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DSIF.CIION <br /> L Indicate the LEAK DHI'lCTION system(s) used to comply with the monitoring requirements for the tank. <br /> VT. INFORMA710N ON TANK PERMANE?NI7,Y CLOSED IN PLACE, <br /> L ESTIMATED DATE LAST USED-MONTII/YEAR(January, 1988 or 01/88). <br /> 2. E.SI`IMATED QUANTrI'Y of HAVARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK PILLED WITH INF RT MATERIAL? Check 'Yes'or'NO'. <br /> APPLIC:ANI:'MUST SIGN AND DAIL 71IE?FORM AS INDICATED. <br /> INSTRUCIION FOR 17111 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 Sta*e Board to assign the tank number,please leave it blank. <br /> a IS17111 RESPONSIBIJAY OF 111E LOCAL.AGENCY THAI'INSPE7aC N 711E FAC IlY TO VE:RIFY'ITIE <br /> ACCURACY OF THE INFORMN110N. 1711H LOCAL AGENCY IS RESPONSIBLE FOR THE COMPI.d IION OF TILE <br /> "LOCAL"AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOCIATED <br /> FORM"B*(s)1'O.3N11 FOI.I.OWING ADDRESS. <br /> smho OF CALIFORNIA . <br /> 6STAIE WATER RESOURCES C'ONTROI,BOARD <br /> C/O S.W.F I.P.S. <br /> DATA PROCESSING CENIER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA%M <br />