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71t. ._, <br /> INSTRUCITONS FOR COMPLI-FlING 14ORM*B" <br /> GENI.-RAL INSTRUCTIONS <br /> 1.. One FORM"B"shall be completed for each tank for all NEW PERM.TV N PERMIT CHANGES, REMOVAUS and/or any <br /> other TANK INFORMNIION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLICAN'For 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 FORM:"MARK-ONLY.ONE n7uw <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 DFSCRIP1TON-COMPLETE ALI.rrEMS-W 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.ACMETANK 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 CONIENIIS <br /> A. 1. If MOTOR VEHICLE'S FUEL,check box I 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 I 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 CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,'TANK MATERIAL,INTERIOR LINING and CORROSION PR(XIT"CrION. <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 /> 1 Indicate the LEAK DE-I'ECTION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK Dff1`E(`11ON <br /> 1. Indicate the LEAK DT.7.17ECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INIURMA'11ON ON TANK PERMANENII Y C1,OSED IN PLACE? <br /> 1. ESTIMATED DATE LAST USED-MONTH/YEAR(January, 1.988 or 01/88). <br /> 2. ESTIMATED QUANITIN of HAVARDOUS SUBS`FANCE remaining in the tank(in Gallons). <br /> 3, WAS TANK FILLED WITH INT RI`MATERIAL? Check'Yes'or'NO'. <br /> APPLICANT MU917 SIGN AND DA7117,71113,FORM AS INDICATED. <br /> tNS-MUCIION FOR ITIE 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 /> ri,IS nun RESPONS113111111'Y OF 11111 LOCAL AGE NCIf'171INFINS.P13M 111E FACHnY10 VERIFY 11111; <br /> ACCURACY OF11IF.INFORMA11ON. 11111 LOCAL AGENCY IS RESPONSIBLE FOR'111I3 COMPLU11ON OF 111E <br /> 'LOCAL AGENCY USE,ONLY'INFORMATION BOX AND 17OR FORWARDING ONE FORM W AND ASSOCINIVD <br /> FORM FOLLOWING ADDRESS. <br /> SDVII!OF CALIFORNIA <br /> STATE WATER RE SOURCIS CON I'ROL BOARD <br /> C/O S.W.EE.P.S. <br /> DATA PROCESSING CE:NrER <br /> P.O.13OX 527 <br /> PARAMOUNT',CA 90M <br />