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IN1317RUCIiONS FOR COMPI.FnNG FO&B" • <br /> GLNERAL INMRUCIIONS. <br /> 1. One FORM"B"shall be completed for each tank for all NF?W PERMrIS,PERMrr CHANGES, RF.MOVAI.S and/or any <br /> other TANK INFORMA711ON C:IIANGL <br /> 2. This form should be completed by either the PERMrr APPLICANT'or 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 OF FORM."MARK ONLY ONE nEM' <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 DF.SCRIVIION-COMPI.1?'IE ALL fIT?MS-W UNKNOWN-SO SPIJ£'IFY <br /> A. Indicate owners tank Il:)# -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'I'ANK MI"G.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex.25,000 or 10,0010 etc.). <br /> H. TANK CONTENIS <br /> A. 1. If MOTOR VEHICLI~ FUEL,check box 1 and complete items B & C. <br /> 2.If not MOTOR VI IIICI I 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 FULL,(if box 1 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 /> 111. 'I:ANK CONSL'RUCTION-MARK.ONIi 171EM ONLY IN BOX A,B,C&c D <br /> 1.. Check only one item in"TYPE,OF SYSTEM,TANK MATEIZIAL, INTERIOR 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 011IFI? print in space provided. <br /> 3. Indicate the LLAK DET T C-110N sy-,tcm(s)used to comply with the monitoring requirement for the piping. <br /> V. TANK LEAK DM, T?CTION <br /> 1. Indicate the LEAK DETECTION system(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANF II,Y C)OSED IN PIACI? <br /> 1. ESTIMATED DAlI?I.,AST USED-MON TI/YLAR(January, 1988 or 01/88). <br /> 2. ESTIMAI'I.U.)QUAN71 Y of HAZARDOUS SUBSTANCE remaining in the tank(in Gallons). <br /> 3. WAS'TANK FILLED Wrl'11 INEM'MATERIAL? Check'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DATE'ITII?FORM AS )IC1i IED. <br /> INSTRUCTION FOR11IE:LOCAL A6I24CIFS <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 he 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 /> rl'IS THE RFzSPONSIBHXI'Y OF'ME LOCAL AGINC:Y 71IAT INSPECTS 111E FAQUTY'r0 VERIFY 1II1? <br /> ACC'URAC'Y OF TIIE INFORMATION. 11IE I,CX:AL AGI?.NC:Y IS RESPONSIBLE E FOR 71I13 COMP11Z10N OF TTII3 <br /> 'LOC'AI.AGENCY USB ONLY'INVORMA'TION BOX ANIS FOR FORWARDING ONE FORM'A'AND ASSOCIATED <br /> FORM'B'(s)TO 111B POI.I.OWING ADDRESS. <br /> SVVM7 OF CALIFORNIA <br /> SrA1E WATER RL'SOURCIS CONI'ROI,BOARD <br /> C/0 S.W.E.E.P.& <br /> DATA PROC.'ISSING (XWIER <br /> P.O.BOX 527 <br /> PARAMOUNI',CA 90723 <br />