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INSTRUCTIONS FOR COMPLETING FORM "B„ <br /> GENERAL INSTRUCTIONS; <br /> 1 Orre FG;M "i3L:h i t e r lr;;'.', t Y each tank for, all NEW PERMITS. PERMIT" CHANGES, REMOVALS and/or any <br /> ether TANK INFORMATION CHANGE <br /> Th;,, form houla bc} :',rmp1el,)d l, ' :`ithcr the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECTOR. <br /> 3 Teas+ type, or print cle,lrly all requested information. <br /> 4 Use a hard point writing insrrument. you are making 3 copies. <br /> TOP OF FORM: 'MARK ONLY ONE ITEM" <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 tho ['B^ or Facilily nam+} where the tank is installed. <br /> I . TANK DESCRIPTION • COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br /> r r ed by the awrrer to identify the tank <br /> A. 1'I l.c:'., w't'r'S td"}'. f i4 ..''l' I x tan, number thdt is u <br /> At <br /> B Ir;;cate the rlafrl.41 :,f the comF;nv that: manufactured the tank (ex. ACME TANK MFG). <br /> C. In7lti=ate ,e Year, tf>2 tank w;s in5t.al !ecj (ex. .987). <br /> D. indicate the tank cap'ic i t1v i rl gal I,in (ex. 25,000 or 10.000 etc. ) <br /> II. TANK CONTENTS <br /> A. 1 Ir... M.1TOR VEHICI.4 FUEL, check box I and complete items B & C. <br /> 2. if riot MOTOR VEHICLEE Fl!Fi , check the appr,0priate box iii section A and complete items B & D. <br /> B Check thr='appropriale box <br /> C. ' 6ec'k 11he t.vpe of MO70R ViHICLE FULL (if' box 1 is checked 'in A). <br /> D Pant the chemical name of the hazardous substance stored in the tank and the C.A.S.#.' (Chemical <br /> Abstract. (:ervice numbor ), if box I is NUT checked in A. <br /> III . TANK CONSTRUCTION - MARK ONE ITEM ONLY IN BOX A. B, C & D <br /> 1. Check only one item iii TYPIF OF SYy5JFM TANK MA1FRIAL, INTERIOR LINING and CORROSION PROTE.CTION. <br /> 2. If U'.HFR, print: in the spa_e. provided. <br /> IV. PIPING INFORMATION <br /> I. 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 systems) used to comply with the monitoring requirement for the piping: <br /> V. TANK LEAK DETECTION . <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI; INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED - MO 'HIYEAR (January, 1988 car. 01,`88) <br /> 2. ESTIMAT.Ea 00"kINTITY of HAZA'?DOUS SUBSTANICE remaining in the tank (in Gallons). <br /> 3. . WAS TANK FTLLED WITH INERT M:�TiAL Check 'Yes' or 'NO' <br /> APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The 'state underground storage tank identification number is composed of thetwo digit county number, the three. <br /> digit jurisaiction number, the six digit facility number, and the six digit tank number. The county and <br /> jurisdiction numbers are predetermined and cari be obtained by calling the State Board (916) 227-4303. The <br /> facility number must be the same as shown in form "A". The tank number .may be assigned by the local agency, <br /> however', this number must be numerical and cannot contain an alphabet. If the local agency prefers the State <br /> Board to assign the tank number, please leave it blank. <br /> IT IS THE RESPONSIBILITY OF-THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE <br /> INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX <br /> AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. <br /> • <br />