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q•.'._�. �,.. J',,., .4 w.r ;= i... .9'd.' _ 'N iWp'f'M .,� ; �^ t• i:'Y -¢. .. <br /> 1 . <br /> y " <br /> IN,Si'RUCI'IONS FOR COMPLFIING FORM"B" <br /> GENERAL INSTRUCTION&- <br /> 1. One FORM "B"shall be completed for each tank for all NEW PERMITS,PERMIT C"IIANGFS, REMOVALS and/or any <br /> other TANK INFORMN11ON CHANGE. <br /> 2. This form should be completed by either the PERMCI'APPLICANT or the LOCAL AGENCY UNDERGROUND TANK <br /> 1 EC'1'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?FIN' <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 /> I. '.TANK DPSCRff L1ON-COMPLETE.AI.I.17FEMS-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.A1370789). <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 /> 13. TANK CONI C3NTS <br /> A. 1. If MO'T'OR VEHICLE 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 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 1 is NOT checked in A. <br /> III. TANK CONEIRUC11ON-MARK ONE L'TEM ONLY IN BOX A,B,C&D <br /> 1. Check only one item in TYPE OF SYSTEM,TANK MATERIAL,I:N'TERIOR LINING and CORROSION PROTECTION. <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,paint in space provided. <br /> 3. Indicate the LEAK DFTF.,CITON system(s) 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 /> VL INFORMATION ON TANK PERMANENTLY CIM,3)IN PLACE <br /> I. ESTIMAT'ED DATE LAST USED-MONI'II/YEAR(.January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTTTY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED WI'I7I INERT MATERIAL.? Check'Yes'or'NO'. <br /> APPLIC'AN'T MUSTSIGN AND DA7I14111E FORM AS INDICATED. <br /> IN91RUCIION FOR TILE 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 /> IT IS THE RESPONSIBILITY OP TI IE LOCAL AGENCY THAT INSPECTS TIIE FAC ILCTY TO VERIFY TI IE <br /> ACCURACY OF 11IE INFORMATION. 7HE LOCAL AGENCY IS RESPONSIBLE FOR T1iE COMPLE'I10N OF TFIE <br /> "LOCAL AL AGENCY USE ONLY*E411ORMAI ION BOX AND FOR FORWARDING ONE FORM*A'AND ASSOCIATED <br /> FORM"B"(s)TO THE FOI.I-OWING ADDRESS. <br /> SPATE OF CAMFORNIA <br /> STATE W1ti1J,,1JR RESOURC-S CONTROL BOARD <br /> C,/O S.W.E?Rrs. <br /> DATA PROCESSING CENITM <br /> P.U.BOX 527 <br /> PARAMOUNT,CA WM <br /> f: <br />