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INSTRUCTIONS FOR C OMPI.FrI'ING FO "II' <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM "B"shall be completed for each tank for all NEW PF.RML1, PERMIT CHANGIFS, REMOVALS and/or any <br /> other TANK INFORMATION CIIANGE. <br /> 2. This form should be completed by either the PERAUT APPLICANT or the LOCAL AGF.NC Y UNDERGROUND TANK <br /> INSP Z11OR. <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 OHI Y ONI:31"17m <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,atame where the tank is installed. <br /> I. TANK DESC.7B''1.7ON-COMPII?TE ALL"17ILMS-117 UNKNOWN-SO SPFX1FY <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 CONT WIN <br /> A. 1. If MOTOR 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 1 is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the CA.S.#.(Chemical Abstract Service <br /> number), if box 1 is NOT checked in A. <br /> III. TANK C ONSTRUC11ON-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 PROTECTION. <br /> 2. If OTIiER,print in the space provided. <br /> 1V. PIPING INFORMS17ON <br /> 1. Circle A if above ground;circle U if underground; and circle both if applicable. <br /> 2. If UNKNOWN,circle; or if OTIIER,print in space provided. <br /> 3. Indicate the LEAK DETI CI'ION system(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DETECTION <br /> I. Indicate the LEAK DE`TEC'TION system(s) used to comply with the monitoring requirements for the tank. <br /> VL INFORMATION ON TANK PERMANENTLY CIASED IN PLACE <br /> 1. ESTIMATED DA17E LAST USED-MONII.I/YEAR(January, 1988 or 01/88). <br /> 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS TANK FILLED W TTI I INERT MATERIAL? Check'Yes'or'NO'. <br /> APPLICAMF MUST SIGN AND DATE 111E FORM AS INDICAI"ED. <br /> INSIRUCIION FOR im I ocAI.AG1 NculS <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 /> rr Is TILE RESPONSIBun Y OF'IIIE LOCAL.AGF.NC:Y THAT 1NSPEM TIIE FA.(Mxff TO VERIFY TIII? <br /> ACCURACY OF TLIE INFORMA11ON. TIIE I.AC AL AGENCY Is RESPONSIBLE FOR TI IE?COMPLETION OF THE? <br /> 'LOCAL AGENCY USE ONLY"INPORMNIION BOX AND FOR FORWARDING ONE FORM'A'AND ASSOC:IA'I1:A <br /> FORM'B'(s)TO TIIE:FOLLOWING ADDRESS. <br /> STATE OF CALIFORNIA <br /> STA.II?WAI13R RI::SC)URCFS C ONIROL BOARD <br /> C/O S.W.l,-_P.S <br /> DATA PROC.ISSING CENII?R <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 9t1M <br />